Inquest into the Death of Watmore

Contributing factors

• severe acute tonsillitis with tonsillar enlargement
• patient-controlled morphine analgesia prescribed without adequate monitoring protocols
• failure to escalate critical vital signs deterioration at 2am
• delay in initial medical review (5 hours 15 minutes from ED arrival)
• inadequate nursing observations and monitoring regime
• absence of clear policies for on-call doctor escalation
• no standardised patient-controlled analgesia monitoring chart
• failure to contact on-call doctor after critical oxygen saturation reading
• possible pre-existing sleep apnoea

Coroner's recommendations

1. Health Department work with hospitals without on-site medical staff to establish clear policies and guidelines for nursing staff on when to call on-call doctors and escalation procedures if doctors are unable or reluctant to attend
2. Albany Regional Hospital review arrangements to limit hours worked by medical practitioners and increase after-hours doctor availability
3. All hospitals throughout Western Australia adopt a policy requiring medical review of any patient with unexplained oxygen saturations of 90% or below
4. All hospitals in Western Australia adopt a policy requiring written orders for oxygen therapy once patient is stabilized, with orders retained on or as part of the medication chart
5. Standard form for recording observations in patients receiving patient-controlled analgesia be used throughout Western Australia, enabling multiple entries and recording rousability scores alongside vital signs and infusion details
6. All hospitals in Western Australia adopt an agreed policy for observations of patients receiving patient-controlled analgesia, with consideration given to half-hourly observations for first two hours in opiate-naïve patients, then one-hourly for next two hours, then two-hourly thereafter, recommencing if dose is significantly varied