Holes align in transfer tragedy

Jun 19, 2018

A young man was having drinks with a friend and following going to the bathroom, returned saying that he thought he had passed out and may have bumped his head. The following morning, he attended his GP who referred him to a metropolitan hospital indicating he had developed atrial fibrillation (AF) and experienced an episode of syncope. The attending CMO considered that the patient may have suffered a seizure but formed the impression that the patient's syncope was most likely due to the AF, with which the consultant cardiologist concurred.

The patient was admitted overnight for rate control and anticoagulation and the next day was reviewed by a basic physician trainee (BTP), who discovered the patient may have hit his head. After developing a headache, a CT scan revealed an acute left frontotemporal subdural haematoma. The BPT immediately called the neurological registrar of a nearby tertiary hospital to arrange a transfer.

An intern contacted the tertiary hospital to facilitate the transfer and was told a neurosurgical consultant would have to accept the patient’s care before a transfer could be arranged. However, because a consultant at the tertiary hospital had not yet accepted the patient, the transfer could not be arranged. The intern called the hospital and conveyed the patient’s deteriorating condition to one of the neurosurgical registrars. The neurosurgical registrar informed the on-call consultant about the patient, who agreed to accept him for urgent admission, enabling the completion of the documentation for the transfer.

The patient’s condition worsened rapidly and he was transferred to ICU and intubated after further administrative delays. A Medical Retrieval Service team transferred the patient to the tertiary hospital, by which time his prospects of recovery were poor. Despite a craniotomy and evacuation of the subdural haematoma, the patient died the following day.

The coroner’s finding

It was noted the patient generally received care and treatment that was both adequate and appropriate during that time. However, there were matters identified that suggested scope for improvement in general patient management within the hospital system.

System issues addressed focussed on the inadequacy of the transfer of the patient to the tertiary hospital. The coroner also advised the health department to consider giving targeted training to all nursing and medical staff regarding their policy directive about clinical handovers.

The experience of junior medical staff and the nursing staff who had not previously encountered a situation like the one they faced on the day in question, meant there was miscommunication, a failure to appreciate the urgency of the patient’s clinical situation and the necessary response, and administrative impediments encountered.

Case comment

Dr Susan Hertzberg, MB.BS, MHealthlaw, MBioethics, FACEM, Senior Medical Advisor, NSW

With evidence from around 20 people across two hospitals and three departments, it was important to direct the coroner to the core issues. In this case, it was a series of systems and administrative issues that failed the patient.

We represented two members through the two year process, from reviewing their statements responding to the initial investigation, through to supporting them in giving evidence at the inquest. This was a difficult time for our members, with criticism from expert witnesses and peers having the potential to lead to a referral to the regulator and disciplinary action. It was important the doctors prepared thorough and accurate statements initially, and then referred to their statements when being questioned at the inquest, providing short answers that are direct and factual.

Although system failings were the root cause in this case, it is important for doctors to be aware of their local transfer policies, have clear communications processes and know their on-call responsibilities.

Useful resources

Read our Factsheet: The coroner and you or view our Webinar: More than words; communication and clinical handover.

This article was originally published in Connect issue no. 10

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