Inquest into the Death of Allan

Contributing factors

• Failure to recognise septic shock at triage presentation
• Inadequate vital sign assessment by triage nurse
• Misdiagnosis of presentation as gastroenteritis due to vomiting and diarrhoea
• Failure to escalate to physician despite fever of 39.4°C and serious parental concern
• Inadequate supervision and support of junior, inexperienced triage nurse
• Lack of clear guidance to RN Swoboda regarding need for supervision at triage
• Pre-existing Staphylococcus aureus colonisation from earlier skin infections

Coroner's recommendations

1. WACHS develop a standardised on-line e-learning package for preceptors
2. Nursing rosters make it plain who is a preceptor on any given shift
3. Introduction of a requirement all new nursing staff sign to acknowledge receipt of orientation documentation with an index of documents received
4. Mandatory provision of verbal and written advice to all new nursing staff detailing the differences between working in a tertiary hospital and a regional hospital such as NRH
5. Mandatory provision of verbal and written advice to all new nursing staff detailing the role of preceptors and areas requiring support
6. Mandatory completion of the MR1 patient name and basic observations at every triage presentation unless impossible due to patient consciousness or immediacy of treatment required
7. The Department of Health continue roll-out of the new patient administration system to ensure improved access to clinical information and real-time access to patient data at country hospitals
8. Provision of on-site educational workshops to assist in competency compliance in key areas including triage, with roster support