Inquest into the death of NL

Findings and Recommendations

Findings and Recommendations of Inquest

Case Number: 2019/00124245

Date of Findings: 28 March 2025

Magistrate: Deputy State Coroner, Derek Lee

CORONIAL LAW – cause and manner of death, cardiac arrythmia, QT prolongation, hypothyroidism, compliance with thyroxine medication, endocrine management, thyroid function test, endorsement of pathology results, multidisciplinary team meetings, copying and pasting from eMR, observations of mental health inpatients, team model of nursing, Health Practitioner Regulation National Law (NSW)

Responses

Recommendations

To the Chief Executive, South Eastern Sydney Local Health District:

1. I recommend that a request be escalated to the relevant State entity for changes to be made to the eMR to ensure that any test results for a patient are not checked as endorsed by default, and that instead there is functionality requiring a clinician to manually endorse such test results.

2. I recommend that previous requests for the eMR – Copy and Pasting within Electronic Documentation (SESLHDPR/605) to be amended to include a warning of the dangers associated with copying and pasting information in the eMR be followed up until such amendments have been effected.

3. I recommend that consideration be given to reviewing the nursing model of care which exists in the Kiloh Centre to determine whether staffing numbers, patient-to-nurse ratios, and allocation of clinical responsibilities to nursing staff are sufficient to meet patient loads and ensure patient safety.