Case Number: 2075/06 VIC
Case Précis Author: Carmel Young RN
In this Clinical Communiqué case study, a coronial investigation was required to determine whether there had been systems and communication issues during handover that delayed the identification of the previously diagnosed oesophageal pouch which contributed to the death of an elderly patient under hospital care.
Ms W was a 98 year old independent female who lived in a granny flat behind her grand-daughter’s house. She had a past medical history of arthritis, congestive cardiac failure (CCF) and chronic obstructive airways disease (COAD).
She was diagnosed with an oesophageal pouch in 2001 by a private physician and instructed to maintain a soft food diet. In June 2006, Ms W ate a fish fillet, which regurgitated after swallowing and she developed a sore throat and a deeper cough than normal. Two days later she was found collapsed at home and was taken to a public hospital. She complained of shortness of breath and a productive cough and was diagnosed with left lower lobe pneumonia.
A pneumonia pathway was implemented and she was treated with intravenous fluids and antibiotics. There was no notation in the medical file about her inability to swallow, and no reference made of the previously diagnosed oesophageal pouch in the documentation by the emergency doctor. While in hospital, the nursing notes showed that she vomited after eating and only tolerated fluid orally.
Her swallowing worsened and the ward staff referred her to a speech pathologist and a gastroenterologist, and a gastroscopy was planned following consultation with her private physician. Two days later she was transferred to a private hospital for the gastroscopy, and was diagnosed with aspiration pneumonia.
Her condition deteriorated rapidly and she died the next day.
An autopsy found the cause of death to be bronchopneumonia and pulmonary congestion from an obstructing food bolus within the oesophagus, and cardiac amyloidosis. The forensic pathologist who performed the autopsy commented that the large food bolus within the oesophagus would be expected to lead to significant obstruction to ingestion of food, fluids and medications.
This case was referred to the coroner by the family who expressed concern that Ms W’s inability to swallow had not been taken seriously. They felt that the hospital neglected to obtain a complete past medical history. The grand-daughter reported that she had informed the admitting staff about the oesophageal pouch.
The focus of the coronial investigation was to determine whether there had been systems and communication issues that delayed the identification of the previously diagnosed oesophageal pouch. A number of statements were obtained from the treating medical staff. Hospital staff had no independent memory of such discussions however, and there was no documentation in the medical records of a presenting symptom of dysphagia. At review it was considered that in the setting of an oesophageal pouch Ms W had a chronic risk of aspiration, however there were other significant medical conditions that contributed to her death.
The focus of the coronial investigation was to determine whether there had been systems and communication issues that delayed the identification of the previously diagnosed oesophageal pouch.
The coroner acknowledged that the hospital was able to demonstrate a number of inadequacies in Ms W’s management including lack of documentation regarding the dysphagia and of consultant review. Subsequently, changes had been made to a number of relevant systems for managing patients routinely treated by private physicians, who present to a public emergency department with incomplete records of their medical history. These included formalising routine consultant assessments and clinical handovers within the medical units.
This case highlights the importance of listening to the family when they express concerns and documenting discussions and issues that are raised. It also serves as an example of where breakdown in the transfer of information was an important contributing factor to death. Inadequate clinical handover is a major preventable cause of morbidity and mortality within hospital systems.
Clinical handover refers not only to the transfer of information but also encompasses the transfer of professional responsibility and accountability. The Clinical Handover Standard devised by the NSQHS outlines the criteria for developing structured clinical handover processes and identifies the importance of including patients and carers in those processes. Preparation, involving relevant staff members, identifying the clinical context and needs, and utilising a standardised method of transfer, are all key principles. Underlining each step is the need for detailed, unambiguous, and accurate documentation.
Inadequate clinical handover is a major preventable cause of morbidity and mortality within hospital systems.
In recent years, many Health Services, Colleges and Schemes, have developed local policies for clinical handover utilising tools such as ISBAR, ISoBAR, SHARED and COLD. It is imperative that every clinician working within an organisation identifies and engages with the handover processes for their area.
- Australian Medical Association. Safe handover: Safe patients. Guidance in clinical handover for clinicians and managers. Canberra: AMA, 2006. Available at http://www.ama.com.au/node/4064
- Australian Commission on Safety and Quality in Health Care (2011). Implementation Toolkit for Clinical Handover Improvement. Sydney, ACSQHC.
- Porteous J, Stewart-Wynne E, Connolly M, Crommelin P. ISoBAR – a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust 2009; 190: S152-S156.