The Coroners Court of Queensland recently delivered the Findings of the Inquest into the death of Mr Mark Plumb in October 2014. The communication between staff and the systems to recognise and manage the Patient's clinical deterioration were of particular interest to the Coroner.
On 19 September 2014, the Patient underwent a surgical procedure to remove a gall stone performed by Dr Pitre Anderson at the Friendly Society Private Hospital (FSPH) in Bundaberg. Soon after the procedure the Patient began to experience severe abdominal pain. The results of a CT scan were verbally reported to note a suspected perforation of his duodenum or common bile duct, with free fluid in his abdomen. Dr Anderson ordered conservative treatment. The Patient's condition continued to deteriorate over a period of 11-16hours, during which he became septic, before he was transferred to Wesley Hospital in Brisbane for urgent specialised treatment. The Patient underwent significant surgical and medical treatment but unfortunately died on 23 October 2014.
The Inquest identified three issues for investigation, those being: the appropriateness of the surgical procedure; the appropriateness of the post-operative care, including whether staff recognised and responded appropriately to the Patient's clinical deterioration; and the timeliness of the decision to transfer the Patient to the Wesley Hospital in Brisbane for urgent surgical treatment.
In relation to the issue of the appropriateness of the surgical procedure, the Coroner was satisfied that the performance of elective endoscopic retrograde cholangiopancreatography (ERCP) by Dr Anderson at the FSPH was clinically indicated and appropriate. However, the inquest identified communication and systems breakdowns that occurred over the 12 or so hours that followed. The Patient had increasing pain and urinary retention. The nursing staff reported this to the surgical intern, Dr Low, who reviewed the Patient. There was concern about the level of pain that the Patient was experiencing, despite his vital observations appearing normal.
Dr Low discussed the Patient's condition with Dr Anderson who conducted a review and considered that the Patient had post ERCP pancreatitis, which he anticipated would be self limiting. Dr Anderson inserted a catheter which drained 400ml of urine, said to have reassured Dr Andersen that the Patient was not in renal failure. At this time the Patient did not have any signs of peritonism but Dr Anderson ordered a CT scan and blood work. Dr Anderson did not record the details of his review, as it was his usual practice for the nurses to document the verbal orders he provided. The Coroner made particular mention of this sub-standard level of record keeping as a contributor to the communication and system breakdowns of patient management.
The Coroner sought the independent expert opinion of Dr Phil Lockie. Dr Lockie considered that up until this point the post-operative care of the Patient was appropriate. However, Dr Lockie considered the CT scan a "game changer" and from this point on was critical of the standard of care provided by Dr Anderson as well as the systems in place at FSPH regarding the clinical management of the Patient as he deteriorated overnight. Both of which are opined to have led to a delay in transfer to the Wesley Hospital for specialised treatment.
The CT scan was never formally reported, the verbal report was given to Dr Anderson who elected, without reviewing the Patient, to adopt a conservative course of treatment to the likely perforation and free fluid. This decision by Dr Anderson informed the decisions of the FSPH staff who cared for the Patient overnight. The medical and nursing staff continued a conservative treatment course without contacting Dr Anderson because they were reassured by the fact that he had spoken to the radiologist about the CT scan. This was despite the fact that the Patient's condition had considerably worsened since the last review by Dr Anderson and the performance of the CT scan. The Patient was showing signs of developing early biliary sepsis and/or pancreatitis. The action taken overnight was to escalate antibiotic therapy and rehydrate the Patient. A miscommunication between medical and nursing staff led to Dr Anderson not being contacted until approximately 5.30am who arrived to examine the Patient one to one and a half hours later. Blood tests showed acute renal failure and a CT scan showed evidence of a bile duct or duodenal perforation. At approximately 9.30am the Patient was referred to the Wesley Hospital in Brisbane and was transferred via Careflight later that day.
The Coroner considered the events overnight demonstrated communication and systems breakdowns. The independent expert, Dr Lockie, described Dr Anderson's note keeping as inadequate which led to critical information being unavailable to the team looking after the Patient overnight.
The Inquest also considered the reviews undertaken by FSPH following this episode of care. The FSPH conducted a Root Cause Analysis and evaluated their procedures, tools and competency. An Acute Pain Management police was developed and further education was provided in relation to the track and trigger observation chart that was in place at the time of care. Further, the policy for escalation of concerns about deteriorating patients was revised. Finally, a Patient Communication Board has been placed in each room to improve communication among the medical and nursing care team.
The Coroner found that "An earlier recognition of deterioration and transfer for appropriate care would likely have improved Mr Plumb's chances of survival..." The Coroner relied on the expert advice of Dr Lockie who considered the CT scan to have been a "game changer" and the start of the period where there were multiple "missed opportunities" for the escalation of concerns about the deterioration of the Patient's condition. On the basis of the reviews conducted by FSPH and the fact that following Dr Anderson's retirement the FSPH has not sought for accreditation to perform ERCPs, the Coroner did not consider it necessary to make any further recommendations.
Although management of a patient can be attributed to a single practitioner, it is important to have in place systems to guide and allow the escalation of concerns about a patient's condition.
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