Inquest into the Death of Edmiston

Contributing factors

• Excessively deep bladder biopsies performed by inexperienced registrar without adequate supervision
• Failure to review patient post-operatively for 22 hours despite deterioration
• Delayed administration of antibiotics (8+ hours after ordering)
• Poor writing and communication of antibiotic orders on medication chart
• Failure to insert urinary catheter promptly despite orders
• Delayed initiation of intravenous fluids
• Failure of supervising urologist to attend hospital despite serious findings
• Failure to escalate to intensive care unit when indicated
• Unavailability of senior clinician due to social commitments and alcohol consumption
• Administrative confusion regarding patient disposition (expected discharge vs ward admission)
• Failure of nursing staff to escalate concerns appropriately
• Absence of clear handover and communication between medical staff

Coroner's recommendations

1. All hospitals in Western Australia should conduct routine audits of Medication Charts to ensure they are correctly written up and that newly appointed or transferred medical practitioners are familiar with the particular charts in use and know how to correctly fill them out
2. Medication Charts should be written up to indicate when first medications are to be given and when regular doses are to be given, specifically indicating whether there is to be a variation in regular delivery immediately after the first dose
3. Joondalup Health Campus should put in place a Morbidity-Mortality Conference Procedure to help identify patterns of complications and aid in early identification of impaired surgeons who may benefit from available help
4. In future contracts entered into by hospitals in Western Australia with consultants and other medical practitioners, terms and conditions of appointment should specifically require provision of information regarding any medical condition, including psychiatric diagnoses, which could be relevant to the performance of that practitioner
5. Hospital contracts should require provision of information about any medication, such as anti-depressant medication, which could impact on the ability of the practitioner in question