Serious 4B Delayed treatment. Admitted with sepsis (infection) ED pre-assessment prior to ward secondary to septic arthritis and placement reviewed and staff educated necrotising fasciitis of left leg. Delayed about expectations. ED to use North referral by primary practitioner for ICU Shore Early Warning Score (NEWS) review. Deteriorated on ward. prior to transfer from ED. Transferred to regional ICU post-op for Reinforce expectation that antibiotics cardio respiratory support secondary to must be given on time as prescribed. multi-organ failure following four Strict compliance with NEWS policy. procedures (compartmental fasciectomies). Increased orthopaedic registrar involvement. Plastic surgery was carried out at another hospital. The patient’s leg and all Improved communication. the muscles were saved. Serious 6 Unwitnessed fall Patient was admitted for alcohol No recommendations identified. resulting in head withdrawal (Section 9 of the ADA Act injury (subdural 1966). Diagnosis of sub-dural haematoma) requiring haematoma due to fall. surgery. Patient required surgery to drain haematoma. Serious 6 Unwitnessed fall In seclusion due to poor mental No recommendations identified. resulting in cervical A CT scan of the head and cervical spine fracture (broken neck) identified neck fracture (unstable C4/C5 requiring surgery for unifacet fracture dislocation). Taken to unstable cervical theatre for surgery (C4/C5 anterior spine fracture/ cervical discectomy and fusion). Routine dislocation. uncomplicated procedure. Admitted to ICU post-procedure. Serious 6 Inpatient fall resulting Assessed as high risk. Appropriate in fractured hip measures in place. requiring surgery.
Serious 4B Delayed treatment. Admitted with sepsis (infection) secondary to septic arthritis and necrotising fasciitis of left leg. Delayed referral by primary practitioner for ICU review. Deteriorated on ward. Transferred to regional ICU post-op for cardio respiratory support secondary to multi-organ failure following four procedures (compartmental fasciectomies). Plastic surgery was carried out at another hospital. The patient’s leg and all the muscles were saved. ED pre-assessment prior to ward placement reviewed and staff educated about expectations. ED to use North Shore Early Warning Score (NEWS) prior to transfer from ED. Reinforce expectation that antibiotics must be given on time as prescribed. Strict compliance with NEWS policy. Increased orthopaedic registrar involvement. Improved communication. Serious 6 Unwitnessed fall resulting in head injury (subdural haematoma) requiring surgery. Patient was admitted for alcohol withdrawal (Section 9 of the ADA Act 1966). Diagnosis of sub-dural haematoma due to fall. Patient required surgery to drain haematoma. No recommendations identified. Serious 6 Unwitnessed fall resulting in cervical fracture (broken neck) requiring surgery for unstable cervical spine fracture/ dislocation. In seclusion due to poor mental A CT scan of the head and cervical spine identified neck fracture (unstable C4/C5 unifacet fracture dislocation). Taken to theatre for surgery (C4/C5 anterior cervical discectomy and fusion). Routine uncomplicated procedure. Admitted to ICU post-procedure. No recommendations identified. Serious 6 Inpatient fall resulting in fractured hip requiring surgery. Assessed as high risk. Appropriate measures in place.