Inquest into the death of Andrea Lester

Case Number: 2018/00190647

Date of Findings: 21 December 2022

Magistrate: Deputy State Coroner, Magistrate Erin Kennedy

Catchwords: CORONIAL LAW – Wollongong Hospital, tracheostomy, subarachnoid haemorrhage, thunderclap headache, PICA, speaking valve, tracheostomy cap, Swedish nose, tracheostomy management, multidisciplinary team

Responses

Recommendations

To the Illawarra Shoalhaven Local Health District (LSLHD):

1. That the role of the Intensive Care Unit (ICU) Consultants (or representatives of ICU on the Tracheostomy Review Team) – as set out in the ‘ISLHD Tracheostomy Review Team – Terms of Reference’ (November 2022) – must include a requirement to attend a bedside MultiDisciplinary Team review on patients who have tracheostomies on outlying wards (such as Ward C4 West - Neurological and Neurosciences Ward) (Ward C4 West) as necessary. 
2. That the role of Ear, Nose and Throat (ENT)/Head & Neck (ENT/H&N) Clinical Nurse Specialist (CNS) 2 role, in the ISLHD be increased from a part-time to a full-time position (ongoing). 
3. That the Executive Director of Nursing and Midwifery Services will ensure that the nursing staff who are available to provide care for patients with a tracheostomy in Ward A5, Ward C4 West, and any other wards within the Wollongong Hospital (other than ICU) who have tracheostomy patients, are competent in tracheostomy management and, in doing so, will have regard to competency assessments undertaken by the ENT/H&N CNS 2. 
4. That the Executive Director of Nursing and Midwifery Services will ensure the Nurse Unit Managers are aware of the obligation to ensure that the nursing staff rostered and allocated to care for patients with a tracheostomy in Ward A5, Ward C4 West and any other wards within the Wollongong Hospital (other than ICU) who have 4 tracheostomy patients are competent in tracheostomy management. 
5. That recommendations (1) to (4) be actioned as a matter of urgency, given the significant clinical risk associated with tracheostomy management on outlying wards (such as Ward C4 West) that do not frequently have such patients. 
6. That the Chief Executive of the Illawarra Shoalhaven Local Health District give consideration to the use of appropriate equipment for constant monitoring of oxygen levels with alarm systems when weaning tracheostomy patients who have decreased levels of consciousness or cognitive impairment.