A SERIES of “errors, misunderstandings and failures” by medical staff at two Darling Downs hospitals contributed to the deaths of a teenage girl and woman, 86, a coroner has found.
The failure of an on-call doctor at Oakey Hospital to have his phone charged, when a nurse tried to call him about Mrs Verris Wright’s deterioration, was “inexcusable”, Deputy State Coroner John Lock said.
Mr Lock was delivering joint findings into the sepsis-related deaths of Verris Dawn Wright, 86, at Oakey Hospital in 2013 and Jasmyn Carter, 17, at Warwick Hospital in 2014.
Mr Lock said nursing staff did not recognise the seriousness of Mrs Wright’s condition and did not have a “plan B” when a nurse could not contact the on-call doctor.
Mrs Wright died from septic shock due to a bowel obstruction on Boxing Day, 2013, after not being reviewed by a doctor or given any treatment over a four-hour period.
She had presented at the hospital two days before and was sent home without any x-ray planned.
“There were a series of almost unbelievable errors, misunderstandings and miscommunications which contributed to this tragic set of events,” Mr Lock said.
Jasmyn Carter died from meningococcal septicaemia after an unexplained drop in blood pressure, that should have prompted an emergency response, was not acted upon, Mr Lock said.
Jasmyn was admitted to Warwick Hospital a day after complaining of headaches, dizziness and aches, after playing Australian Rules football.
Mr Lock said a plan for more frequent observations and a review by a Warwick Hospital doctor was not put in place because of errors, misunderstandings and miscommunications.
“As a result the signs of emerging sepsis, which no doubt would have become more evident over the coming hours, we’re not recognised and acted upon,” Mr Lock said.
Jasmyn died at the hospital at 3.30am the next day, August 4, 2014.
He said timely and appropriate treatment may have changed the outcome.
“Of considerable concern and distress for Jasmyn’s mother was that no one at the hospital telephoned her to tell her about Jasmyn’s deterioration and the emergency situation until after Jasmyn passed away,” Mr Lock said.
In both cases clinical staff failed to explore sepsis as a possibility of the patients’ conditions.
After Mrs Wright’s death Darling Downs Hospital and Health Service implemented the Queensland Adult Deteriorating Detection System tool to help staff respond to deteriorating patients.
Despite the QADDS tool being in place before Jasmyn Carter’s death, it was not acted upon, Mr Lock said.
An emergency call should have been made about her low blood pressure soon after her attendance at the hospital.
Queensland Health recognised there was a “culture of complacency” about hospital staff completing early warning and response system tools paperwork.