Inquest into the Death of Walden

Contributing factors

• Failure to identify prior 1998 cholecystectomy despite documentation in medical records
• Dr A. failed to read medical history in his referral letter
• Mr Clarke did not read the medical history in the referral
• Hospital pre-admission clinic did not have access to patient's hospital records
• Pre-admission nurse not trained on TOPAS system to access prior admission records
• Radiologists incorrectly identified gallstones where no gallbladder existed
• Unnecessary surgical dissection causing duodenal perforation
• Sepsis in immunocompromised patient on steroids for rheumatoid arthritis
• Deceased did not volunteer information about previous cholecystectomy
• No system in place to alert clinical staff when pre-admission completed without medical records
• Hospital records not available at pre-admission clinic despite being requested
• Computer-assisted copy-paste of medical history without verification

Coroner's recommendations

1. Medical practitioners should be wary of over-reliance on technology when preparing correspondence and should check carefully any medical histories pasted into correspondence
2. Sonographers should exercise caution when relying on a patient's own version of medical history involving the gallbladder
3. In all ultrasound cases, previous images and reports should be reviewed including, if at all possible, those produced by other agencies
4. Greater than usually cautious attention should be paid to even slight variations in presentation exhibited by a patient known to have been prescribed steroids
5. Post-operative interactions between doctors and patients should be recorded in hospital notes
6. Hospital pre-admission procedures should ensure medical records are available and if not available, ward staff should be alerted that clarification of patient history may be required
7. Implementation of team time-out procedures before each surgical procedure
8. Improved protocols for calling Code Blue with lower thresholds for oxygen saturation levels
9. Continued improvement of hospital systems for timely access to medical records
10. Review and enhancement of TOPAS computer system to be more clinically useful