Date of Findings: 22 June 2017

Coroner: Ainslie Kirkegaard

Inquest Place: Brisbane

Date of Death: 1 March 2015

Factual Summary:

Gwendoline Mead was a 73 year old woman who died 12 days after surgery at the Toowoomba Base Hospital on 1 March 2015 from complications of surgery to treat recently diagnosed high grade synchronous caecal and rectal tumours.

Post-operatively, she experienced persisting low urine output and intermittent asymptomatic hypotension resulting in acute kidney injury and urosepsis. She deteriorated rapidly and suffered coagulopathy likely exacerbated by bleeding from injury to her left femoral artery due to repeated attempts to insert an arterial line to facilitate intensive care monitoring.

Having regard to the autopsy findings and the clinical history, the cause of death was determined to be multiple organ failure due to, or as a consequence of sepsis due to, or as a consequence of rectal and caecal adenocarcinoma (surgically treated).

Issues for Consideration:

  1. The adequacy of the multidisciplinary team approach to Mrs Mead’s care.
  2. The appropriateness of the surgical decision making.
  3. The adequacy of communication between multiple treating teams about Mrs Mead’s post-operative condition and its management.
  4. The adequacy of the pre-operative assessment and planning of Mrs Mead’s care.
  5. The appropriateness of Mrs Mead’s discharge from the ICU on 25 February 2015.
  6. Whether aspects of Mrs Mead’s clinical management reflect broader system failures and if so, what systems changes could be made to minimise the risk of adverse health outcomes in the future.

Conclusions:

  • The inquest identified a number of missed opportunities to have optimised Mrs Mead’s care. It is not certain whether those opportunities would have been outcome changing for Mrs Mead, however they were significant in maximising the potential for better clinical outcomes.
  • Doctors involved in Mrs Mead’s pre and post-operative care were asked to provide formal statements responding to the issues identified by preliminary and independent expert review. The Darling Downs Hospital & Health Service (DDHHS), while acknowledging there was a delay in seeking medical review, did not believe it would have changed the course of events. The clinical review team was satisfied Mrs Mead was managed by a multidisciplinary team and believed the decisions made were reasonable. It recommended review of the capacity of the hospital’s patient flow management system to better record and action inter-team referrals.
  • Expert Dr Steven O’Donoghue considered Mrs Mead’s care might have been improved if a senior physician was involved after a pattern of multiple MET calls for her recurring problems. He suggested this approach could have resulted in a clearer plan for her management and transfer to a High Dependency Unit environment for closer haemodynamic monitoring and more aggressive interventions to manage her hypotension and low urine output. In turn this may have resulted in earlier investigation of why she was not sustaining a response to fluid therapy. However, his report stopped short of expressing an opinion as to whether this approach would have changed the outcome for Mrs Mead.
  • Dr O’Donoghue also questioned whether a more aggressive transfusion approach and earlier decision to undertake a CT angiogram and surgical repair might have been more successful in achieving earlier control of the bleeding in Mrs Mead’s thigh during her readmission to ICU.

Recommendations:

Improved pre-operative communication within the Surgical Oncology Multidisciplinary Team environment

  • The most significant of the missed opportunities flows from the surgical team not being involved in Mrs Mead’s management during her second November 2014 admission. The Surgical Consultant’s involvement in investigating and managing her bowel complications at this stage of her neoadjuvant treatment would have better positioned him to reassess the planned surgical approach in light of those complications
  • Notwithstanding potential improvements to the SOMDT model to enhance surgical team awareness of emerging pre-operative issues, it remains incumbent on senior and junior members of all teams involved in a cancer patient’s pre-operative and post-operative care to actively read the patient’s chart.

Improved response to multiple MET calls or escalation for recurring problems

  • Prior to Mrs Mead’s acute deterioration with sepsis on the afternoon of 23 February 2015, nursing staff appropriately escalated these recurring hypotension and low urine output issues to Ward Call for review on eight occasions and on one occasion, initiated a MET call. As such these issues were attended to in a sporadic and reactive way.
  • Dr O’Donoghue suggested a system whereby patients having multiple MET calls for a recurring problem can be identified and referred to a senior clinician for timely review. This would help commence appropriate investigations earlier, facilitating communication between senior members of the treating teams, enabling earlier escalation to intensive treatment if appropriate. For example, the Royal Brisbane & Women’s Hospital implemented a system whereby on weekdays there is a two hour period for the acute inpatient physician led team to review patients who having MET calls or especially multiple MET calls.

Improving the management of inter-team requests for patient review

  • Ward-based doctors involved in Mrs Mead’s post-operative course sought advice from or requested formal review by members of the medical team.
  • The DDHHS SAC 1 Clinical Review identified the potential for inter-team referrals to become lost when they are unable to be captured properly on a paging system or patient list that is generated daily for each team, especially when the information is written on a piece of paper or committed to memory. It recommended review of the hospital’s patient flow management system (Patient Flow Manager) to assess its capability to record and action these requests.
  • DDHHS has since developed capability within Patient Flow Manager to record and action formal requests for patient review. Once entered, the request is forwarded to the clinician via their smart phone alerting them to the referral and requesting their review of the patient. The patient’s name appears on the referrer and receiving team handover sheets as a patient requiring consult. The request remains current in Patient Flow Manager until the review is undertaken and closed on the system. It was hoped to trial the system in early February 2017.

Perioperative medicine

  • A broader perioperative approach to the management and treatment of elderly patients was considered. If adopted, the Medical Team would likely have been involved in Mrs Mead’s management from the outset meaning she would have been on their radar at an earlier stage positioning them to have been better able to influence or guide her management throughout.

Improving clinical documentation

  • The poor clinical documentation in Mrs Mead’s case is not uncommon – the quality of clinical documentation is a concern in many health care related death investigations and inquests.

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