Inquest into the death of Robert Bischard

Case Number: 2017/49625

Date of Findings: 17 August 2022

Magistrate: Deputy State Coroner, Magistrate Joan Baptie

Catchwords: CORONIAL LAW – manner and cause of death, care and treatment at Wagga Wagga Base Hospital, pre-operative screening processes in the context of comorbidities

Responses

Recommendations

To the Murrumbidgee Local Health District:

1. That the Murrumbidgee Local Health District give consideration to establishing a structured peri-operative acute shared care model or pathway targeted at identifying and managing risks during surgical admissions in patients with significant co-morbidities 
2. That the Murrumbidgee Local Health District audit the use of daily fluid balance charts, the standard clinical pathway for a total knee replacement, and nursing compliance with medical requests for the completion of additional observations (such as postural blood pressure readings) on the Orthopaedic Inpatient Unit. 
3. That the Murrumbidgee Local Health District conduct further case presentations with staff (that is, targeting nursing, medical and surgical staff) using Mr Bischard’s case as an anonymised case study to prompt discussion around:
   a) The need to carefully chart routine medications and allergies (given the prescribing of MS Contin notwithstanding a reported allergy to sulphur and the initial prescribing of Metoprolol as a 50mg dose each morning rather than 2 x 25mg doses each day.)
   b) Adequate completion of daily fluid balance charts and the standard clinical pathway for total knee replacement.
   c) Recognising “low urine output persistent for 8 hours” as a red zone criteria under the NSW Health Between the Flags protocol.
   d) The need for post-operative plans to be documented in the medical record in a timely fashion and for nurses to implement plans for additional observations where requested (such as recording postural blood pressure readings).