Inquest into the Death of Morgan John EDWARDS

Contributing factors

• Absence of support person/care worker accompanying non-verbal patient to emergency department
• Erroneous assumption by registrar that care home had registered nurses for monitoring
• Failure to obtain imaging due to patient agitation and decision not to sedate
• Discharge without definitive diagnosis despite elevated respiration rate (26 breaths/minute) and elevated lactate
• Lack of clear documentation of discharge reasoning and instructions
• Inadequate discharge plan providing vague monitoring instructions without specific symptom guidance
• Failure of care home staff to return patient to hospital despite clinical deterioration
• Early Warning Score system that resets to zero after hospital discharge without accounting for recent hospitalisation
• Care home staffing lacking registered nurses despite patient's complex needs
• Failure to escalate within care home despite EWS scores of 5 and documented clinical concerns
• Limited collateral history available to ED staff due to absence of familiar care worker
• Intermittent presentation of volvulus making diagnosis challenging

Coroner's recommendations

1. Identitywa should urgently amend its 'Going to Hospital Guidance' and 'On Call File: Responsibilities' documents to clearly state that residents will always be accompanied by a care worker to hospital except where resident has capacity and declines support or guardian/next-of-kin attends instead
2. Identitywa should issue urgent bulletin to all staff reminding them of the current policy regarding hospital admissions and respective responsibilities of care workers, team leaders and On-Call
3. Identitywa should engage suitably qualified health professional to review Early Warning Score system and amend the EWS Response Chart to account for residents recently discharged from hospital who are still exhibiting symptoms, and to ensure observations after discharge do not automatically start at score of zero
4. Identitywa should amend Transfer to Hospital file documentation to include (on front) a single A4 summary sheet with critical information about resident (NOK details, medical conditions, medications, allergies) and brief statement of reason for referral to hospital
5. South Metropolitan Health Service should amend discharge summary policy to provide greater clarity and detailed instructions regarding symptoms to be monitored and circumstances for hospital re-admission, with particular attention to non-verbal patients and residents of supported accommodation without clinical staff
6. South Metropolitan Health Service should advise ED clinicians to adopt lower threshold for admission for non-verbal patients where no definitive diagnosis has been established following initial assessment and examination