Inquest into the Death of Ashleigh Rebecca HUNTER

Contributing factors

• ED overcrowding resulting in delayed admission
• Triage Code 3 allocation despite severe pain warranting Code 2
• Failure to recognize sepsis presentation without fever or rash
• Cognitive bias: symptoms attributed to drug use rather than infection
• Delayed transfer of care from Ramp to ABay to ED
• Fragmentation of care across multiple interfaces
• Lack of adequate pain management during ED delays
• Absence of real-time vital signs monitoring and information sharing between St John Ambulance and hospital
• Difficulty obtaining blood pressure readings due to patient agitation

Coroner's recommendations

1. That the Department of Health consult with Health Service Providers with regard to implementing a single electronic medical record.
2. That the Department of Health on behalf of Health Service Providers consult with St John Ambulance to consider pathways allowing real-time access to relevant portions of the St John Ambulance electronic medical records system, including sharing of Corpuls Monitor data.
3. That the Department of Health on behalf of Health Service Providers consult with St John Ambulance to consider the development of a shared, consistent documentation process to record the deceased's observations taken by St John Ambulance within the medical records of Health Service Providers.
4. That EMHS consider the development of a clear and consistent documentation process to record decisions made by the Emergency Physician in Charge (EPIC) in the event that the EPIC declines to escalate patient care after a request is made, or a concern is raised, by a clinician.
5. That the Department of Health consult with relevant stakeholders to develop a body of work to establish a working definition of an 'emergency,' for the purposes of: (1) Developing strategies to reduce Emergency Department overcrowding; and (2) Educating the community and building awareness about 'responsible use' of an Emergency Department, including the use of examples of specific situations in which Emergency Department services could appropriately be used, or not used.
6. That EMHS consider additional education and audits on the use of the 'Adult Sepsis Pathway,' with additional educational focus on encouraging a high index of clinical suspicion for sepsis by clinicians, including nurses who undertake triage assessments, who may ultimately treat a patient with an unusual sepsis presentation.
7. That clear guidelines between the Department of Health, hospitals (including East Metropolitan Health Service), and St John Ambulance be established regarding the duties and responsibilities of St John Ambulance Paramedics or Ambulance Officers to escalate patients, in circumstances where there is ambulance ramping, or any other delay in assessment of a St John Ambulance patient by a Triage Nurse.
8. That the Department of Health consider funding an established non-government organisation to develop and implement a Public Awareness Campaign regarding the availability of the Meningococcal ACWY vaccine, and the Meningococcal B vaccine, to advise those who want to protect themselves against meningococcal disease that they can speak to their vaccination provider about getting vaccinated, particularly the cohort that would not have been vaccinated within the free National Immunisation Program.