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.
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
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.
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
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.
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
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
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.
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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