Coroner's Court of Western Australia

Inquest into the Death of Cyril CHURCHILL

Inquest into the Death of Cyril CHURCHILL

Delivered on : 26 March 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

For the guidance of clinicians, Western Australian Country Health Service (WACHS) should, as a matter of priority, develop a policy for the use of point of care ultrasound (PoCUS), including FAST scanners.  The policy should set out minimum education, training and credentialing requirements for practitioners using PoCUS as well as guidance as to the appropriate clinical circumstances in which PoCUS should be used.

Recommendation No. 2

WACHS should amend its Health Records Management Policy to provide guidance to staff as to exactly what constitutes a medico-legal report and why such documents may not appear on a patient’s health record.

Recommendation No. 3

WACHS should amend its Health Records Management Policy to provide that, as a general rule, entries made by clinicians in or for a patient’s health record are not to be removed, left unfiled or deleted.  Where the person in charge of a health service determines that a clinician’s entry is to be removed from, or not placed in a patient’s health record, that person should clearly document (in the relevant health record), exactly what has been removed or not placed on the patient’s medical record and the reasons for that decision, having regard to any issues of legal professional privilege that may attach to the document.  Further, any document containing a clinician’s entry that has been removed or not placed on a patient’s health record should be retained by the relevant health service.

Recommendation No. 4

WACHS should take steps, including the provision of training, aimed at improving communications between clinicians involved in patient care.  In particular, WACHS should ensure that in a situation where clinicians disagree as to the management of a patient, there is a process in place to resolve that disagreement in a timely and efficient manner.

Recommendation No. 5

WACHS should amend its clinical Escalation Including Code Blue – Medical Emergency Response Policy to provide that the role of Medical Emergency Response Team Leader is clearly identified at the start of the Medical Emergency Response call and thereafter when that leadership role changes.

Orders/Rules : N/A

Suppression Order : N/A

Summary :  Cyril Churchill (Mr Churchill) died at Royal Darwin Hospital (RDH) on 13 November 2017 from surgical complications following the removal of his inflamed gallbladder.  He was 68 years of age.

Mr Churchill was transferred from Fitzroy Crossing Hospital to Broome Hospital on 26 October 2017 following a three day history of abdominal pain.  His gallbladder was removed laparoscopically on 27 October 2017 and following the procedure, Mr Churchill’s blood pressure became dangerously low despite repeated doses of medication, intravenous fluids and blood transfusions.

Mr Churchill’s treating team considered two possible explanations for his symptoms.  The first was that he was experiencing internal bleeding and the second was that the symptoms related to an infectious process, most probably a septic shower.  Mr Churchill was treated for both possibilities, but his condition failed to improve.

Mr Churchill was eventually returned to theatre, where three litres of blood was removed from his abdomen before he was transferred to RDH.  Following initial an improvement in his condition, he deteriorated and was transferred to the RDH hospice where he died, surrounded by his family, on 13 November 2017.

The coroner concluded that Mr Churchill’s treating team should have identified that internal bleeding was the more likely cause of Mr Churchill’s symptoms and that he should have been returned to theatre at earlier stage.  On the basis of the available evidence and given Mr Churchill’s pre-existing medical conditions, the coroner was unable to conclude that the outcome in his case would have been different had he been returned to theatre earlier.

The coroner found the standard of record keeping in Mr Churchill’s case was suboptimal.  Too many of the entries in his medical record were retrospective, important information had not been captured and records relating to another patient had been inadvertently included in the file.

The coroner made five recommendations aimed at improving the standard of medical records and to improve the quality of communications between clinicians involved in a patient’s care, especially where there was disagreement between clinicians about the cause of a patient’s clinical condition.

The coroner found the cause of Mr Churchill’s death was surgical complications following laparoscopic cholecystectomy for cholecystitis and that his death occurred by way of misadventure.

Catch Words : Communication and management of patients in a hospital setting : Accurate note taking : Misadventure

Last updated: 22-Apr-2022

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