Inquest into the Death of Eric Clarence Moody

Contributing factors

• Failure to formally assess level of consciousness and self-care capacity before discharge
• Failure to recognise ongoing alcohol absorption during time in ED
• Inadequate assessment of suitability for discharge to family care
• Lack of guidance to family on monitoring for aspiration and life-threatening signs
• Poor communication with family regarding dangers of severe intoxication
• Absence of doctor on site; incomplete information provided to on-call doctor
• Family not given carer instructions despite severely intoxicated state
• Cultural and communication barriers with family that impaired information transfer

Coroner's recommendations

1. Include in Remote Area Nursing guidelines and Rural Emergency Nurse Survival Kit an easy-to-follow checklist to ensure compliance with guidelines for assessment of intoxicated patients
2. Develop an information sheet for carers of intoxicated patients leaving Emergency Department, outlining signs and symptoms to monitor (e.g. laboured breathing, snoring, cyanosis, depressed consciousness, changes in vital signs)
3. Expand cultural awareness section in guidelines with clarification of concepts of blame and responsibility relevant to community groups served
4. Add section reminding health providers that people in unfamiliar circumstances frequently do not absorb information coherently and need simple checklists of 'do's' and 'do nots'
5. Ensure guidelines emphasise that intoxicated patients require ongoing assessment during their time in ED, not only on arrival