Inquest into the Death of Susan Jessica Elsie WINDIE

Contributing factors

• delayed recognition of abdominal compartment syndrome
• process of junior registrars determining transfer acceptance rather than consultants
• underestimation of urgency by registrar advice
• lack of clear escalation plan when conservative treatment failing
• inadequate communication pathway between rural and tertiary hospitals
• failure to transfer earlier despite worsening clinical signs
• multiple phone calls required to arrange transfer delaying urgent care

Coroner's recommendations

1. Implement centralised coordination of transfer requests through senior physicians or a command centre rather than first-contact junior registrars
2. Establish direct access to consultant specialists for rural doctors managing complex or unusual presentations
3. Lower the threshold for transfer acceptance when rural doctors express concern about unusual or complicated cases
4. Implement a system allowing rural doctors to escalate requests and speak with senior colleagues when dissatisfied with registrar advice
5. Establish a central communication hub for transfer requests (similar to models in Queensland and New Zealand) to streamline the process and reduce delay
6. Ensure registrars discussing transfer requests have appropriate supervision and discussion with senior colleagues before making decisions
7. Improve support to rural hospitals from tertiary centres for management of complex cases
8. Implement the proposed WACHS Command Centre acute patient transport coordination service
9. Continue implementation of the Call and Respond Early (CARE) call system to address family concerns