There have been a number of recent cases relevant to emergency departments. This article briefly summarises some of the relevant cases and draws from them lessons to be learned.
On 5/6 March 2006 Aileen Dawn Promnitz, a 79 year old resident at St Hilarion Nursing Home at Lockleys, was conveyed by ambulance to the Queen Elizabeth Hospital because of dehydration resulting from the deterioration in her health. She was triaged as Priority 4 and, according to the Australian Triage Scale, should have been seen by a doctor within one hour. Unfortunately, she was left for six hours on a trolley in a corner of the Emergency Department waiting room without being seen by a medical practitioner, where she remained until a member of the public found her to be deceased. During that time, she was seen twice by a nurse and on both occasions her vital signs were normal.
The Coroner found in his report dated 3 June 20101 that Mrs Promnitz's death (a result of sepsis due to a urinary tract infection) was avoidable and the support for nursing home patients by general practitioners in South Australia was inadequate.
The Hospital made the following changes to reduce mortality arising from overcrowding:
- There is now a nurse in the Emergency Department whose role it is to assist the triage nurse. This assistant is assigned solely to maintain contact with patients in the waiting room and ensure that they are observed.
- There is now a formalised over-capacity policy, which means that the ED can call a 'Code E' across the hospital to signal to other parts of the Hospital that they require assistance. At this call all senior medical staff and consultants within the hospital are required to assess existing patients for discharge and critically determine whether any capacity exists for the transfer of patients from within the ED to medical wards. Triggers include where there are more than 45 patients in the ED, or where there are 35 patients but also 10 awaiting admission, and where there is a patient in category 2 who has been waiting for over 30 minutes.
- A new ward has been added to this hospital which is calledthe Diagnostic and Planning Unit.
The strategies introduced by the Queen Elizabeth Hospital may be helpful for other health care facilities currently attempting to reduce access block in their ED's orsuccessfully implement the 4-Hour Rule.
Emergency Room miscarriage
On 25 September 2007 Jana Horska miscarried in the toilet of Royal North Shore Hospital's emergency room. Jana was triaged as Priority 4, that is, a patient with a potentially serious condition, to be treated within one hour. The level of activity in the Emergency Department that night was extremely high. Despite complaining of acute pain, she did not receive medical treatment within one hour and miscarried after two hours of acute pain. Her partner Mark Dreyer complained to emergency staff but was repeatedly told to sit down and wait. His wife had already had a miscarriage that year.
Professors Clifford Hughes and William Waters investigated the case and recommended a new protocol for the treatment of women presenting at Emergency Departments with threatened miscarriages. The recommendations included:
- women who arrive at hospital displaying signs of a complication in early pregnancy, and whose condition is assessed as unstable are now placed in a higher triage category; and
- the Emergency Department at Royal North Shore Hospital should be changed to improve the experience of patients: changes to the physical environment of the waiting room, improvements in communication skills of frontline triage nurses and the provision of written information to patients on how emergency departments work.
Multiple errors and omissions - Lack of communication and inadequate medical notes
Vanessa Anderson was a 16 year old girl who tragically died at Royal North Shore Hospital after being admitted with a head injury inflicted by a golf ball.
The State Coroner found that there was poor communication between her doctors, staffing inadequacies, no or inadequate medical notes, poor clinical decisions, ignorance of protocols and incorrect decisions made by nursing staff.2
Ultimately, Vanessa's cause of death was found to be from a respiratory arrest due to the depressant effect of opiate medication. She had been given four times the therapeutic dose of opiate analgesia after her anaesthetist misread her medication chart. However, one of the initial short fallings of the hospital that resulted in her death was that the on call consultant neurosurgeon was not told that Vanessa had been admitted to the ward under his care.
In addition, Vanessa's attending senior resident doctor, a Dr Nicole Williams, had omitted to write the word 'or' between two analgesics she had prescribed in the alternate for Vanessa. On 18 December 2009 Dr Williams was found by the NSW Professional Standards Committee to be guilty of unsatisfactory professional conduct relating to the requirement to keep proper medical records (including concerning the medication order of parenteral morphine).3
1. South Australia, State Coroner, Aileen Dawn Promnitz - finding of inquest, 3 June 2010.
2. New South Wales, State Coroner, Inquest into the death of Vanessa Anderson, 24 January 2008.
3. New South Wales, Professional Standards Committee Inquiry, Inquiry into a complaint in relation to Dr Nicole Williams, 18 December 2009
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