Inquest into the Death of McLevie

Contributing factors

• Failure to initiate antibiotics despite fever at 3am (38°C)
• Failure to initiate antibiotics despite second elevated temperature at 6:50am (38.7°C)
• Consultant did not review medical records during ward round
• Inadequate handover communication regarding patient's temperatures from resident to consultant
• Failure to recognise medical emergency criteria (systolic BP <90, low urine output)
• Registrar failed to visit patient or review notes
• Poor communication between junior doctors and senior consultant
• Inadequate response to alarming vital signs at ~4:45pm (BP 80/60)
• Four-hour gap without observations between 4:45pm and 8:30pm
• Resident medical officer was most senior doctor on duty overnight
• Inadequate supervision of very junior and inexperienced residents
• Registrar did not attend ward round
• Staffing shortages - no registrar on call
• Insufficient senior medical staff coverage

Coroner's recommendations

1. Consider appointment of obstetric registrars who would be on site so that the most senior doctor present would not be a resident
2. Osborne Park Hospital Medical Emergency calling criteria be available in laminated documents placed at strategic points within the hospital
3. Training for both medical and nursing practitioners should provide greater focus on appreciation of the significance of vital sign observations and proper understanding of criteria which constitute a medical emergency
4. Osborne Park Hospital review its systems relating to involvement of registrars to ensure they take close supervisory role in relation to inexperienced resident medical officers and involve themselves in treatment of all unwell patients
5. Review of puerperal pyrexia guidelines in Osborne Park Hospital to ensure that when an otherwise healthy mother has an elevated temperature of 38°C or more on two occasions separated by a significant period of time, there is immediate introduction of appropriate antibiotics
6. Osborne Park Hospital review its protocols and procedures to ensure immediate response to concerning observations reflecting significant deterioration in patient's condition
7. Training for both medical and nursing practitioners should provide greater focus on importance of accurate and complete communication of significant changes in patients' conditions to senior practitioners, including component focused on effective communication between resident medical officers and registrars/consultants
8. Health Department take action to improve training of nursing staff to ensure consistency in recording of Integrated Progress Notes and Nursing Observations, including mandating that time in margin relates to time of making note and ensuring nurses record actual time of observations in date/time column