Serious 4C Patient deterioration. Review found patient’s Review endorsed the DHB’s existing Referred to Coroner at time of Concern that there was treatment was in keeping with implementation of an Early Warning event. a delay in transfer to the clinical guidelines, although in Score Chart and mandatory Medical The Early Warning Score Chart Intensive Care Unit. hindsight earlier transfer to Emergency Team call system for and the mandatory Medical Patient died. Intensive Care should have predetermined parameters. Emergency Team call system been undertaken. Review also recommended that the have been implemented. The service agree the most appropriate service has agreed the pathway pathway for the care of complex for the care of complex patients. patients experiencing deterioration; The Patient at Risk team are able and to consider whether the Patient at to contact the ICU registrar or Risk team should have the ability to consultant at any time if directly request the opinion of an concerned about a patient’s Intensive Care doctor where they are condition. concerned regarding patient management. Serious 4B & 5 Unexpected patient Review found that the main Review recommended development of It was identified that the had death following factor that contributed to the organisation wide guidelines for the not been referred to the Coroner anticoagulant treatment patient’s death was the diagnosis and treatment of at the time. Coroner for suspected heart decision to treat the patient for myocardial infarction (heart attack) and subsequently notified. attack (non-STEMI a non-STEMI myocardial that the guidelines be developed and Development of the guideline is myocardial infarction). infarction (heart attack) on the agreed between the emergency, under way. basis of Troponin T test cardiology and internal medicine results. Review also noted services. that double the intended dose of anticoagulant was prescribed and given as a first dose due to human error, and that an algorithm included in guidance related to a new high sensitivity Troponin T test may contribute to the risk of such an event.
Serious 4C Patient deterioration. Concern that there was a delay in transfer to the Intensive Care Unit. Patient died. Review found patient’s treatment was in keeping with clinical guidelines, although in hindsight earlier transfer to Intensive Care should have been undertaken. Review endorsed the DHB’s existing implementation of an Early Warning Score Chart and mandatory Medical Emergency Team call system for predetermined parameters. Review also recommended that the service agree the most appropriate pathway for the care of complex patients experiencing deterioration; and to consider whether the Patient at Risk team should have the ability to directly request the opinion of an Intensive Care doctor where they are concerned regarding patient management. Referred to Coroner at time of event. The Early Warning Score Chart and the mandatory Medical Emergency Team call system have been implemented. The service has agreed the pathway for the care of complex patients. The Patient at Risk team are able to contact the ICU registrar or consultant at any time if concerned about a patient’s condition. Serious 4B & 5 Unexpected patient death following anticoagulant treatment for suspected heart attack (non-STEMI myocardial infarction). Review found that the main factor that contributed to the patient’s death was the decision to treat the patient for a non-STEMI myocardial infarction (heart attack) on the basis of Troponin T test results. Review also noted that double the intended dose of anticoagulant was prescribed and given as a first dose due to human error, and that an algorithm included in guidance related to a new high sensitivity Troponin T test may contribute to the risk of such an event. Review recommended development of organisation wide guidelines for the diagnosis and treatment of myocardial infarction (heart attack) and that the guidelines be developed and agreed between the emergency, cardiology and internal medicine services. It was identified that the had not been referred to the Coroner at the time. Coroner subsequently notified. Development of the guideline is under way.
SSE-cases-2010-11-FINALv1.docx