WAhospital

Inquest into the Death of Maria Donatelli

Deceased

Maria Donatelli

Demographics

72y, female

Date of death

2003-02-07

Finding date

2005-09

Cause of death

Peritonitis due to perforated diverticulum in transverse colon

AI-generated summary

Maria Donatelli, a 72-year-old woman with cardiac and renal disease, presented to Peel Health Campus with abdominal pain and vomiting. She was initially managed conservatively with a provisional diagnosis of pancreatitis or bowel obstruction. During overnight observation in the surgical ward, her clinical condition deteriorated markedly from approximately 22:00 hours on 6 February 2003, with progressively declining blood pressure (85/56 to 70/53) and hypoxia. However, these vital sign changes were attributed to mechanical dehydration and analgesic effects rather than clinical deterioration from sepsis. The responsible surgeon (Mr Khamhing) was not notified of the deterioration. At approximately 06:30 hours, she was found in cardiogenic shock and was transferred to Fremantle Hospital where she died at 11:24 hours. Post mortem confirmed peritonitis from a perforated diverticulum in the transverse colon. Key failures included: inadequate interpretation of deteriorating vital signs, failure to escalate to the surgeon despite clear clinical parameters warranting concern, communication breakdown regarding hospital protocols for notifying admitting surgeons, poor documentation of interventions and observations, and use of an unfamiliar agency nurse in a coordinator role without adequate support.

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Specialties

general surgeryemergency medicineintensive caregeneral medicinegeneral practice

Error types

diagnosticcommunicationsystemdelay

Drugs involved

tramadolmetoclopramidehyoscine butylbromideprochlorperazinemorphinemotiliumhaemocell

Clinical conditions

peritonitisperforated diverticulumbowel obstructionpancreatitissepsisshockhypovolaemiahypotensionatrial fibrillationischaemic heart diseasehypertensionrenal dysfunctiongastroenteritis

Procedures

intravenous fluid administrationIV cannula insertionblood samplingx-ray imagingelectrocardiogramoxygen therapymanual blood pressure measurementintubationresuscitationblood transfusion

Contributing factors

Failure to recognise clinical deterioration despite abnormal vital signs (blood pressure 85/56 and 70/53)
Misattribution of deterioration to mechanical dehydration and analgesia rather than sepsis
Failure to escalate deteriorating condition to admitting surgeon (Mr Khamhing)
Communication breakdown regarding hospital protocol for notifying admitting surgeon
Inadequate and infrequent clinical observations (gap from 17:45 to 22:45 hours, then inadequate recording between 22:45 and 02:00 hours)
Use of agency staff unfamiliar with hospital protocols and night shift procedures
Unavailability of regular night shift registered nurse for surgical ward
Shortage of nursing staff requiring allocation of night manager to alternative area
Lack of documentation of significant clinical decisions and fluid rate changes
Patient's significant comorbidities (cardiac disease, hypertension, renal dysfunction) limiting physiological reserve
IV line problems causing delays and requiring resiting, complicating fluid resuscitation

Coroner's recommendations

Hospitals must be vigilant in ensuring nurses appropriately record significant and relevant clinical actions and observations in patient charts and progress notes
More comprehensive orientation for agency nurses should be instigated to prevent repetition of communication and protocol failures
Hospital protocols for notifying admitting surgeons of patient deterioration must be clearly communicated to all nursing staff
Vital signs should be assessed holistically and in context; deteriorating observations should be flagged for escalation even if physical presentation appears reassuring
Fluid rate changes in patients admitted for observation should be accompanied by adequate documentation and appropriate follow-up observations
Regular nursing staff should be maintained on critical shifts; where agency staff are used, they should not be assigned to coordinating or managing roles without adequate support and orientation

Full text

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