Inquest into the death of Jarrod Wright –  17 December 2018 and 18 January 2019

Mr Jarrod Wright (42) had been admitted and was being treated for cellulitis in his right thigh at Liverpool Hospital on 30 June 2016 when complications arose and ultimately ended in his death on 9 July 2016. The inquest into Mr Wright’s death considered whether Mr Wright’s treatment in the intensive care unit (ICU) and, in particular, the nursing-to-patient ratio in the ICU, had been appropriate.

Facts

On 3 July 2016, Mr Wright was transferred from the orthopaedic ward to ICU after nursing staff had encountered difficulty maintaining intravenous access to administer his antibiotics (which caused Mr Wright to miss some doses on 1 and 2 July) and Mr Wright had become hypoxaemic, with the levels of oxygen in his blood sinking to 60%.

In ICU, it was suspected that Mr Wright was suffering acute respiratory distress syndrome (ARDS), which is respiratory failure characterised by rapid onset of inflammation in the lungs. In order to improve Mr Wright’s respiratory function, he was placed on oxygen support ventilation administered through a mask (CPAP).

However, Mr Wright became increasingly frustrated with his non-rebreather mask and then refused to use it at all. The registered nurse (RN) informed the ICU registrars that he was concerned that Mr Wright’s agitation was adversely impacting his ability to comply with treatment. He secured a dose of Diazepam to help settle Mr Wright.

At around 3pm, Mr Wright became angry and frustrated when he was told he should use a bedpan instead of accessing the toilets. Mr Wright removed his blood pressure cuff and refused to replace it or to take any further Diazepam.

Later, after the RN had returned from his meal break, he found that Mr Wright had disconnected from his monitor again to go to the bathroom and that his oxygen levels had dropped. The RN remained in Mr Wright’s room until he was satisfied that Mr Wright’s oxygen saturation levels had returned to an acceptable level. He called for assistance from the ICU registrars, at which point a sedative of Dexmedetomidine in the form of an infusion was prescribed.

From 7pm, a new RN had taken over the shift and stayed with Mr Wright until 10pm. In that time, Mr Wright remained agitated and continually attempted to remove his oxygen mask, with the result each time that his saturation levels dropped to between 60 and 80%. Also during that time, the senior ICU registrar requested that the RN increase Mr Wright’s ventilation pressure.

When Mr Wright fell asleep at approximately 10pm, the RN left the room to attend to his other patient. Fifteen minutes later, the RN returned and found Mr Wright lying across his bed with the monitoring leads detached. There was a trail of blood and faeces from the bathroom. The RN replaced Mr Wright’s oxygen mask and raised the alarm, noting that Mr Wright’s skin was bluish in colour, he was unresponsive and his breathing was shallow. Mr Wright’s care was escalated to life support.

Although the resuscitation team achieved a return to spontaneous circulation, Mr Wright had received significant brain damage due to his lack of oxygen. On 9 July, Mr Wright’s family made the difficult decision to remove him from life support.

Cause of death

At the inquest, the medical experts generally agreed that the cause of Mr Wright’s death was his failure to receive sufficient oxygen to maintain his cardiac function with the immediate triggering event being the removal of Mr Wright’s oxygen support (likely by himself). It was considered that the reason Mr Wright required oxygen support was most likely related to the effect of the Escherichia coli (E. coli). It was not possible to diagnose a distinct cause for the E. coli septicaemia, although the experts considered it unlikely to have been the thigh cellulitis, which was resolving at the time Mr Wright’s respiratory distress developed.

Appropriateness of nursing ratio

At the time of Mr Wright’s death, the local hospital guideline regarding nurse/patient ratios stated that patients who were critically ill or ventilated, required a 1:1 nursing ratio. This included intubated and ventilated patients, patients who were on non-invasive ventilation and patients who were restless, agitated and clinically unstable. It appeared to the deputy coroner that the guideline had been interpreted in such a way that CPAP ventilation did not always require 1:1 nursing.

In the opinion of Associate Professor Richard Lee (intensive care specialist and anaesthetist), Mr Wright was too agitated to cooperate with his essential oxygen support and, in the circumstances where Mr Wright was suffering a severe hypoxemic lung condition, intubation was justified or, at the very least, continuous nursing observation required.

It was the evidence of the junior registrar and the nursing unit manager that they were not aware of the severity of Mr Wright’s agitation or the extent to which it was placing him at risk. The deputy coroner took this as an inference that, had they been aware, they would have acknowledged that Mr Wright met at least one of the existing criteria for 1:1 nursing, namely that Mr Wright was ‘restless, agitated and clinically unstable.’

Accordingly, the deputy coroner concluded that Mr Wright did not receive appropriate nursing care allocation and that the reason for this was related to a ‘lack of effective communication’ regarding Mr Wright’s nursing needs together with ‘a lack of clarity as to the criteria for 1:1 nursing.’ She adopted as a recommendation a submission from the NSW Nurses & Midwives Association that there would be benefit in upgrading the revised guideline to the status of a policy directive. In doing so, the deputy coroner noted that, where the guideline for the 1:1 ratio that had been in place at the time of Mr Wright’s death and had either not been properly understood or properly regarded by ICU staff, revising the guideline to a policy directive would enhance its importance.

The deputy coroner noted:

It is acknowledged that nursing and medical staff receive training to assist them with such communication issues. Despite thisthe personal and cultural impediments to effective communication within hospital hierarchies remain a recurring feature in the circumstances of hospital deaths like [Mr Wright’s].

Commentary

This case is particularly interesting because the Coroner had specifically mentioned the issue of staffing ratios as a potential contributor to the adverse outcome.