Inquest into the Death of Steele

Contributing factors

• delay in medical assessment (7 hours 10 minutes before seeing doctor)
• delay in transfer to definitive care (over 10 hours before Royal Flying Doctor Service contact)
• failure to recognize time-critical illness
• inadequate telephone consultation and clinical assessment
• misdiagnosis as gastroenteritis based on single bowel movement
• failure to escalate care despite critical vital signs (blood pressure 80/50)
• lack of on-site medical practitioner in town
• on-call doctor located 50km away in Bruce Rock
• absence of Medical Emergency Team (MET) system
• inadequate review of medical records by attending doctor

Coroner's recommendations

1. The Department of Health of Western Australia should adopt guidelines similar to those prepared by the Critical Care Council which would require, if there is no doctor in town but MET criteria are satisfied, that a senior nurse be called in and contact be initiated immediately with a doctor in a nearby town and possibly the Royal Flying Doctor Service. MET calling criteria should require nursing staff to initiate a response to obtain medical assistance locally and seek advice on managing the clinically unstable patient. The use of such a system should encourage overseas trained medical practitioners without local network access to specialist expertise to have a direct mechanism for interacting with suitably qualified and experienced specialists or consultants.
2. Training should be provided to country medical practitioners, particularly those providing telephone consultation, to establish a sophisticated process for telephone diagnosis which includes reporting and recording of information about vital signs and emphasizes potential issues requiring urgent medical assessment or Royal Flying Doctor Service transfer.