Inquest into the Death of Chubby

Contributing factors

• Acute Streptococcus pneumonia infection acquired within 6-12 hours of death
• Multiple terminal chronic conditions: cardiac cirrhosis, heart failure, COPD, diabetes mellitus type 2, pulmonary hypertension
• Failed emergency ambulance call-out protocol
• Inadequate assessment by nursing staff without A&E experience
• A&E nurse did not directly evaluate patient or speak with caller
• Failure to recognise acute deterioration from clinical signs (respiratory distress, slurred speech, dribbling, difficulty breathing)
• Ineffective communication between distressed granddaughter and hospital staff
• Staff disregarded patient's known terminal status and recent hospitalization

Coroner's recommendations

1. The ambulance call-out protocol should be reviewed and staff should receive appropriate training on assessment of emergency calls. The coroner noted this has since been rectified with all ambulance calls now triaged through trained operators in Perth rather than local hospital staff.
2. Hospital staff making triage decisions for emergency calls should have appropriate A&E training and experience.
3. Direct communication between emergency callers and experienced triage nurses or A&E staff should be ensured rather than relying on information relayed through junior or inappropriately trained staff.
4. Recognition of the vulnerability of distressed lay callers, particularly young Aboriginal women, in emergency situations; staff should be trained in trauma-informed communication.