An inquest into a man’s death while in custody after suffering a burn injury raises key lessons for doctors.
The scope of the inquest encompassed a wide range of issues including the importance of venous thromboembolism (VTE) risk assessment and management, and use of the Electronic Medication Management (eMeds) software system when charting medications.
A man was at home when he was told his electricity would be disconnected due to unpaid bills. Police were called after he attempted to cut down a power pole with a chainsaw.
The man continued to behave aggressively including splashing petrol in the vicinity of police officers. Following unsuccessful attempts to subdue the man using capsicum spray, the police used a Taser. This ignited the petrol, causing burns to the man’s left leg. He was taken by ambulance to hospital for treatment for the burn injury.
That evening, the patient was transferred to another public hospital for treatment in a specialist Burns Unit. A plastic surgery registrar assessed him as suffering a partial thickness burn injury to his left leg which extended to his left toe and comprised 5% of his total body surface area. A Xenograft Biobrane dressing was applied following scrubbing of the wound. The patient was then for discharge. However, given the timing of his admission and his complaints of hip pain, it was decided he should remain in hospital overnight and be discharged the following morning.
The next day, the patient became very distressed when an RSPCA officer informed him of concerns about the welfare of his dogs and that two of his dogs had been seized.
Due to the unusual circumstances of the patient’s admission, he underwent psychiatric assessment. A preliminary assessment found he had no signs of psychosis, depression or suicidal thoughts. After further psychiatric review, he was commenced on an Alcohol Withdrawal Scale and prescribed diazepam for agitation and thiamine. Plans were made to obtain information about his past mental health history and for daily psychiatric review to be conducted to monitor his risk of self-harm.
Shortly after the assessment, a bedside hearing was conducted regarding the charges against him. He was refused bail and remanded into the custody of Corrective Services officers, in hospital, pending a future court appearance.
The next day around midday, the patient was reviewed by a consultant psychiatrist. He admitted thoughts of self-harm and wanting to die due to the potential loss of his dogs and house. Towards the end of the review, he revealed he had swallowed a set of keys in an apparent act of self-harm. A later x-ray showed the keys had progressed and it was decided to wait for him to pass them.
Four days later about midday, the patient complained of dizziness and pain in his abdomen and left leg, and later, of dizziness and nausea, and he was observed to be sweating heavily after walking to the shower. His vital signs were normal. A CT scan of his abdomen and pelvis was performed to locate the position of the keys. A preliminary report showed no bowel perforation or other complications in the abdomen.
Early the next morning, the Burns Unit Senior Medical Officer reviewed the patient. While he had an elevated heart rate, his other vital signs remained below the levels for clinical review and there was no evidence of hypoxia. As the burn had healed adequately, the plan was to transfer him to the medical unit at Long Bay Gaol as soon as possible.
Later that morning, the patient was informed his dogs were to be euthanised. He became visibly upset and was crying loudly. Moments later, he was seen to fall from his chair and collapse face down on the floor. He was unresponsive. Cardiopulmonary resuscitation was commenced, but the patient could not be revived and was pronounced deceased.
About the time resuscitation attempts were being made, the final report on the CT scan was being produced. The report noted, “There are possible filling defects within pulmonary arteries in the right lower lobe, raising the possibility of pulmonary emboli. A CT pulmonary angiogram is suggested to further assess this. The admitting team has been notified.”
Cause of death
Handing down his findings in the Coroner’s Court of NSW, the coroner concluded that the cause of the patient’s death was pulmonary thromboemboli due to deep vein thrombosis on a background of a leg burn wound.
eMeds issue impacts patient care
Issues addressed at the inquest included whether the patient was appropriately assessed and managed for the risk of VTE, and use of the eMeds software system for charting prophylaxis in this context.
The coroner noted the NSW Health Policy Directive, Prevention of Venous Thromboembolism (the Policy Directive) was in force at the time. It set out a number of mandatory requirements:
- All adult patients admitted to NSW public hospitals must be assessed for the risk of VTE within 24 hours and regularly as indicated/appropriate.
- Patients identified at risk of VTE are to receive the pharmacological and/or mechanical prophylaxis most appropriate to that risk and their clinical condition.
- Attending Medical Officers (or their delegate) are to ensure regular review of VTE risk is performed during the patient care episode, particularly as clinical condition changes, and that prophylaxis is monitored and adjusted accordingly.
The Policy Directive provides for the use of the VTE Risk Assessment Tool (VTERA Tool) which requires the assessment of a patient’s risk of VTE, allocating them a risk category, considering 21 VTE risk factors and providing appropriate prophylaxis. The tool also states, “Patients should be reassessed when clinical condition changes or regularly (every seven days as a minimum).”
The coroner concluded that the admitting registrar performed a VTE assessment as part of his overall management of the patient but did not prescribe heparin or any other form of DVT prophylaxis because he believed the patient would be discharged within a short period of time.
The Senior Resident Medical Officer gave evidence that it was his standard practice to chart heparin because he did not know whether a patient would remain an inpatient or be discharged.
The patient’s eMeds listed heparin as one of the charted medications. However, it had been charted in error by another doctor who intended it for another patient. After the error was detected, the heparin was cancelled. Unfortunately, the Senior Resident Medical Officer did not see that the heparin had been cancelled. This was because on the eMeds chart, the cancellation entry was located in a column labelled “Status” which could not be viewed on the computer monitor he was using as it wasn’t wide enough to display all the information. There was no indication that to locate the “Status” column, he had to scroll to the right-hand side.
The Senior Resident Medical Officer also explained that prior to the patient’s admission, the hospital had used a hardcopy version of the VTERA Tool. However, with the hospital’s transition to eMR there was no electronic equivalent of the VTERA Tool available.
The coroner concluded that although neither the admitting registrar nor the Senior Resident Medical Officer used the VTERA Tool or any other documentary checklist, each performed a VTE assessment. “The only reasons why the assessments did not result in the prescription of VTE prophylaxis was because of the anticipated duration of [the patient’s] admission and a mistaken belief that pharmacological prophylaxis had already been prescribed,” the coroner concluded.
Consideration of whether use of the VETRA Tool should be mandated led the coroner to state that given the patient’s vital signs were stable and only one of the 21 risk factors on the VETRA Tool applied to him, it is most likely that any assessment would not have led to VTE prophylaxis being prescribed.
“On the evidence available in [this] case this tends to mitigate against the mandated use of the VTERA Tool,” the coroner concluded.
In relation to the eMeds software system issue, the coroner noted that “such a simple technological impediment can adversely impact patient care is cause for concern.” This led him to make some key recommendations to the Local Health District.
In consultation with the NSW Ministry of Health, the coroner recommended consideration be given to requesting the eMeds software system developer to ensure users are readily able to distinguish between medication that is actively being administered to a patient and medication that has been cancelled, irrespective of the on-screen information chosen to be displayed by the user, and without detracting from the functionality and usability of the system.
The coroner also recommended considering using the circumstances of the patient’s death as a case study to educate clinical staff regarding VTE risk assessment in the context of unexpected extension of a patient’s admission duration.
Since the patient’s death, the hospital has introduced a number of measures to mitigate the risk of VTE for patients including:
- The development of an electronic risk assessment tool to assist clinical staff in assessing the risk of VTE, which forms part of the eMR.
- Training for new junior medical staff regarding the eMR and electronic risk assessment tool.
- The creation of VTE risk assessment forms for medical and surgical patients, with the latter completed by medical officers for each elective surgery patient prior to surgery.
- Annual and ongoing education sessions provided to Junior Medical Officers and Basic Physician Trainees on VTE risk assessment.
- Use of an updated VTERA Tool, including an electronic version for use in the eMR and an e-learning module.
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