Inquest into the death of Maureen Smith

Case Number: 2018/103054

Findings Date: 23 August 2023

Magistrate: Harriet Grahame

CORONIAL LAW | Glen Innes District Hospital; Armidale Rural Referral Hospital;  referral of medical practitioner to the Medical Council of NSW; signs of clinical deterioration due to sepsis; septicaemia; septic arthritis; Between the Flags; inter-hospital transfer delays; systems for inter-hospital transfers in regional areas; vital signs observations

Responses

Recommendations

The Medical Council of NSW

1. That Dr Jauncy Natukokona (also known as Robert Hakwa) be referred to the Medical Council of NSW for investigation of his clinical conduct and that a copy of these findings be forwarded to assist with that investigation.

Glen Innes District Hospital

2. An audit process of appropriate nursing records should be undertaken at Glen Innes District Hospital, including the use of Standard Audit General Observation charts, fluid charts, recording of hourly rounding and recording of observations, with a view to improving these matters to attain an acceptable standard if the result of that audit were to demonstrate system issues. Such audit should be conducted at least twice yearly, for a trial period of two years and the capacity to be ongoing, in order to identify trends.

Hunter New England Local Health District, NSW Ambulance and Patient Transport Services

3. That communications between transport agencies in relation to a patient transfer should involve the treating doctor whenever possible, but especially in relation to any potential change to the medically agreed timeframe, to avoid incorrect information concerning the diagnosis or urgency being passed on second or third hand.

Hunter New England Local Health District and Patient Transport Services

4. That an inter-hospital booking for specialist treatment cannot be made with Patient Transport Services (via any method, whether directly or via Patient Flow Unit) unless a medically agreed timeframe has been agreed between the sending and receiving staff (by doctors unless unavailable) and recorded in the Patient Transport Services system.

5. That the Hunter New England Local Health District urgently consider and address the following issues as part of the pilot Medically Agreed Timeframe Project:

a. provide a solution for obtaining a medically agreed timeframe where the three-way phone call between the Patient Flow Unit, the referring clinician and the accepting clinician is bypassed;

b. provide certainty that a “force function” can be implemented in the Patient Flow Portal and the Patient Transport Services Computer Aided Dispatch when the booking does not come through the Patient Flow Portal;

c. provide a mechanism to enforce the Local Health District updating changes to the medically agreed timeframe in the booking system;

d. clarify the trigger for the proposed escalation pathway for notifying the Local Health District when Patient Transport Services does not have capacity to conduct a transfer including whether it is an automated or a human function;

e. clarify whether the proposed notification system leaves time for the patient transfer to be reallocated to another service in order to meet the original medically agreed timeframe; and

f. remove the time estimate pre-generated by the Patient Transport Services booking system as it risks confusing the medically agreed timeframe.

Hunter New England Local Health District

6. That Patient Flow Unit should record telephone calls in order to further improve training and performance, including to assist with accurate audits of the number of patients transferred within the relevant medically agreed timeframe.

NSW Ambulance

7. That NSW Ambulance consider undertaking an audit of outcomes from overflow transfer requests including:

a. whether they were triaged through the Virtual Clinical Coordination Centre;

b. whether NSW Ambulance undertook the transfer within 24 hours or otherwise; and

c. whether (and the circumstances in which) the transfer request was sent back to Patient Transport Services.

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