Inquest into the Death of Roderick Leslie CARTER

Contributing factors

• Delay in obtaining off-site medical review due to prioritisation of documentation over telephone contact
• Atypical presentation with indigestion and shivering obscuring acute myocardial infarction diagnosis
• Limited on-site medical resources at small rural hospital
• Defibrillator left in manual mode at 30 joules instead of emergency setting of 200 joules
• Insufficient nursing staff to simultaneously perform resuscitation, manage airway, and obtain medical advice
• Emergency Telehealth Service not available at time of presentation (Sunday evening)
• Lack of clarity in 2014 regarding ATS 2 priority—whether documentation should precede medical contact
• Delay in reaching additional nursing staff during cardiac arrest
• Failure to fax ECGs to off-site doctor prior to arrest due to disruptions and documentation focus

Coroner's recommendations

1. Ensure 24/7 access to telemedicine services such as Emergency Telehealth Service in regional hospitals
2. Clarify protocols in chest pain pathways that for ATS 1 or 2 patients, obtaining immediate medical practitioner input takes priority over completion of documentation
3. Implement standardised resuscitation equipment and trolleys across regional hospital sites with consistent training
4. Ensure all staff conducting manual equipment checks reset devices to default emergency settings after checking
5. Provide face-to-face professional development and on-site orientation to all nurses, including those rostered at short notice
6. Establish better collegiate support and videoconferencing between regional hospitals to improve consistency and staff retention
7. Place communication devices (fax machines, telephones) within the emergency department to facilitate communication without interrupting patient care
8. Develop online advanced life support training resources focusing on ECG interpretation for regional nurses
9. Address registered nurse staffing shortages in regional hospitals to ensure adequate coverage during emergency presentations
10. Ensure credentialed on-call general practitioner coverage or equivalent medical practitioner availability for after-hours emergency department work