Coroner's Court of Western Australia

Inquest into the Death of Morgan John EDWARDS

Inquest into the Death of Morgan John EDWARDS

Delivered on :28 March 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

The Identitywa policy relating to residents being admitted to hospital (the Policy) is that the resident will always be accompanied by a care worker except where the resident has capacity and declines support, or where the resident’s guardian/next-of-kin attends instead.

As a matter of urgency, Identitywa should amend the document entitled: Going to Hospital Guidance, as well as the “Hospitalisation/Medical treatment required” section of the document entitled On Call File: Responsibilities to ensure that both documents accurately reflect the Policy.

Recommendation No. 2

Identitywa should issue an urgent bulletin to its staff reminding them of the requirements of Identitywa’s current policy with respect to residents being admitted to hospital, so as to ensure there is no confusion as to the respective responsibilities of care workers, team leaders and the On-Call.

Recommendation No. 3

Identitywa should engage a suitably qualified health professional to review its Early Warning Score system (EWS) and associated documentation.  The purpose of the review would be to amend the EWS Response Chart to take account of the situation where a resident has recently been discharged from hospital, is still exhibiting symptoms and/or appears “unwell”.  The review should consider the appropriateness of observations made after the resident’s discharge from hospital at an EWS score other than “0”.

Recommendation No. 4

Identitywa should consider amending its Transfer to Hospital file documentation to include (on the front of that file) a single A4 summary sheet setting out critical information about the resident (e.g.: NOK details, medical conditions, current medications, allergies, etc) along with a brief statement of the reason for the referral to hospital.  Although much of the information in the “summary sheet” could be pre-populated, the reason for referral to hospital would probably need to be handwritten in a legible manner.  In the event of an emergency hospital admission, the summary sheet would provide clinical staff with a single point of reference detailing key information about the resident and the reason why the resident has been sent to hospital.

Recommendation No. 5

South Metropolitan Health Service should consider amending its policy relating to discharge summaries to provide greater clarity and more detailed instructions in relation to the symptoms which should be monitored after a patient’s discharge and the circumstances in which the patient should be returned to hospital.

To be clear, directions in a discharge plan to “monitor symptoms” with no indication of the symptoms to be monitored should be avoided.  Similarly, a direction to “bring the patient back to hospital if there are any concerns”, in the absence of guidance as the parameters which should indicate concern, ought to be avoided.

Clinical staff should be reminded that the requirement to provide additional clarity in a discharge plan is particularly important when the patient is a resident in supported accommodation and/or is non-verbal.  Clinical staff should also take account of the fact that staff in supported care facilities will usually not have clinical skills.

Recommendation No. 6

South Metropolitan Health Service should consider advising emergency department clinicians to adopt a lower threshold for admission with respect to patients who are non-verbal and for whom no definitive diagnosis has been arrived at, following the patient’s initial assessment and examination.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Edwards died on 15 August 2018 at Fiona Stanley Hospital (FSH) from complications associated with intestinal volvulus.  He was 31 years old.  Mr Edwards was born with a rare genetic disease that meant he had severe intellectual and physical disabilities.  He also had cerebral palsy, epilepsy and Crohn’s disease and a history of bowel obstructions.  As a result of his medical conditions, Mr Edwards was non-verbal, had limited mobility, and required assistance with most daily activities.  He lived in a care home operated by Identitywa and had been in their care for over 15 years.

At about 7.00 pm on 14 August 2018, a care worker noticed that Mr Edwards’ pulse and breathing had become very rapid.  When his symptoms didn’t improve, the care worker called a locum doctor, but when the doctor had not arrived by 9.00 pm, the care worker called emergency services and Mr Edwards was taken to FSH by ambulance alone, without the support of a care worker.

At FSH, Mr Edwards was assessed and a junior doctor contacted the care home to obtain some additional information about Mr Edwards and his usual presentation.  A chest x-ray was ordered to determine the cause of his respiratory symptoms but could not be performed because Mr Edwards became agitated and would not lie still.  A blood test had shown an elevated lactate level and a further attempt was made to obtain a chest x-ray.  In addition, an abdominal x-ray was also ordered to see if Mr Edwards had a bowel obstruction or perforated bowel.  The second attempt at obtaining x-rays was also unsuccessful.

Mr Edwards’ respiratory rate improved marginally and after he had been under observation for several hours, it was decided to discharge him to his care home.  The senior doctor responsible for the discharge incorrectly assumed that there was a registered nurse at the care home who could monitor Mr Edwards’ condition.  Mr Edwards was sent back to his care home in an ambulance, again unaccompanied by a care worker.

Mr Edwards arrived back at his care home at 4.05 am on 15 August 2018.  He did not look well and at times his breathing  was laboured.   Despite the fact that he vomited his breakfast and was groaning, he was not immediately returned to FSH.  Instead, care workers followed a guidance system called Early Warning Score (EWS), which prompted action based on a resident’s vital signs.  In accordance with the EWS guidance, a care worker contacted Mr Edwards’ GP who advised him to continue monitoring Mr Edwards and be prepared to take him back to hospital.

Mr Edwards was scheduled for an annual review of his Crohn’s disease at 2.00 pm at the FSH outpatient clinic.  When a care worker arrived to collect Mr Edwards, he noticed brown liquid dribbling from Mr Edwards’ mouth.  It was assumed this was some chocolate pudding, but in fact the liquid was later found to be faecal material and was an indication that Mr Edwards was seriously unwell.  The gastroenterologist determined Mr Edwards’ Crohn’s disease was stable, but because Mr Edwards looked unwell and his breathing was laboured, he was referred to the emergency department at FSH (ED) for assessment.

A senior registrar in the ED determined that Mr Edwards critically unwell and may have a bowel obstruction and pneumonia and volvulus.  Mr Edwards was intubated and sedated so that a CT scan could be performed to confirm whether he required surgery, but before the scan could be performed, Mr Edwards went into cardiac arrest.  Despite resuscitation efforts, Mr Edwards could not be revived.

After reviewing all of the available evidence, the Coroner made six recommendations to assist Identitywa and FSH with the management of patients with complex needs, such as Mr Edwards.

Catch Words : Care Worker Support : EWS Score : Discharge summaries : Disability : Recommendations : Natural Causes

Last updated: 6-Oct-2023

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