Inquest into the Death of nilon

Contributing factors

• Incorrect Hospice Referral Form stating 'terminal phase' and false information about cerebral metastases
• Assumption by treating staff that referral for community palliative care meant patient was terminally ill
• Failure to perform medical assessment at St John of God Bunbury before admission to palliative care
• Disregard of patient and family statements that cancer was in remission
• Admission to palliative care ward where routine observations were not required
• Delay in medical review - Dr L. did not attend hospital for 7 hours after Nurse McRae's telephone call
• Failure to diagnose pneumonia despite severe pain and deterioration
• Unilateral 'not for resuscitation' order made without patient or family consultation
• No investigations undertaken to identify cause of deterioration
• No antibiotics prescribed for treatable pneumonia

Coroner's recommendations

1. All hospice referral forms should require the signature of the referring doctor to appear on the front of the form (not just back for medications)
2. Hospice referral forms should contain specific information as to the patient's current condition including whether any diagnosed conditions are aggressive or in remission
3. All services providing inpatient hospice care for symptom control should ensure that appropriate procedures are in place to prevent patients who are not in the end stage of their illness being inappropriately admitted for respite only
4. In the event that either the patient or family members raise concerns as to the appropriateness of a hospice admission, immediate investigations should be conducted to ensure that a mistaken admission has not occurred, particularly if admission is to be equated to consent to a 'Not for resuscitation' order
5. Legislation is needed in Western Australia to clarify rights and responsibilities in caring for patients in palliative care facilities
6. Legislation should be enacted governing the making of 'not for resuscitation' or 'not for cardiopulmonary resuscitation' orders, including: confirmation of terminal illness status based on reliable information from suitably qualified medical practitioners; informed consent requirements with documented record of who provided advice and essential thrust of advice; clear documentation of patient consent or circumstances if consent given on behalf of patient; clear explanation of the effect of any such decision
7. Terminally ill patients in hospices should be actively managed for at least some curable acute illnesses not connected to their incurable disease, particularly when such illnesses produce painful or distressing symptoms, with the extent of treatment to be clarified in advance