Coroners: inquest, health care related death | My Assignment Tutor

CORONERS COURT OF QUEENSLANDFINDINGS OF INQUEST CITATION:Inquest into the death of Michael JamesCalder TITLE OF COURT: Coroners CourtJURISDICTION: BrisbaneFILE NO(s): 2014/2468DELIVERED ON: 2 September 2016DELIVERED AT: BrisbaneHEARING DATE(s): 15 April 2016, 16 -18 August 2016FINDINGS OF: John Lock, Deputy State CoronerCATCHWORDS: Coroners: inquest, health care related death,private hospital admission, headache, concurrentprescription of slow release and fast acting opiatemedication, death due to opiate toxicity,communication and documentation betweendoctors and nursesREPRESENTATION:Counsel Assisting: Ms M JarvisCalder family: Ms A Martens, Maurice Blackburn LawyersDr R Brockett: Ms K Mellifont QC i/b Avant LawHoly Spirit Northside PrivateHospital: Ms J Rosengren i/b Minter EllisonNurse Meadowfair: Mr B Hall i/b Creevey RussellFindings of the inquest into the death of Michael James CalderContentsIntroduction …………………………………………………………………………………………1Issues for Inquest…………………………………………………………………………………1Autopsy results ……………………………………………………………………………………2Medical and Nursing care provided over 8 to 10 July 2014 ………………………..3Evidence of Dr Rodd Brockett………………………………………………………………..8Root Cause Analysis…………………………………………………………………………..11Expert Review by Dr Charles Denaro ……………………………………………………15Expert Report by Dr Peter Lavercombe …………………………………………………17Conclusions on the Issues …………………………………………………………………..19Cause of Death ………………………………………………………………………………20Appropriateness of the health care provided……………………………………….20Findings required by s. 45……………………………………………………………………22Identity of the deceased………………………………………………………………..22How he died………………………………………………………………………………..22Place of death……………………………………………………………………………..23Date of death ………………………………………………………………………………23Cause of death ……………………………………………………………………………23Comments and recommendations ………………………………………………………..23Findings of the inquest into the death of Michael James Calder Page 1Introduction1. Michael James Calder was aged 33. Michael and his partner, Andrea Younghad three young sons together. Andrea described Michael as having a greatsense of humour and fun. He was a caring and very engaging father to his sons,and a loving partner, son and friend. His loss in these tragic circumstancesremains raw for his family and friends.2. Michael was referred by his GP to the Holy Spirit Northside Private Hospital(HSNPH) on 8 July 2014. He had a three day history of severe occipitalheadaches which were throbbing in nature and continuous. He also developedneck pain and stiffness with increasing severity of his headache. He was notedto be febrile. The GP referral letter noted he had similar symptoms four yearspreviously when he was diagnosed with viral meningitis. It is now known thatMichael also had a history of obstructive sleep apnoea, which had been treatedat the same hospital. This history only became known to those treating him afterhe died.3. Whilst in the HSNPH Emergency Department a number of tests wereperformed. He was given analgesia including IV morphine 10mg in total. He wasthen admitted to the ward under Dr Rodd Brockett, a specialist generalphysician.4. During the course of his ward admission Michael received analgesia for theongoing headache including subcutaneous morphine, oxycodone, Ordine (liquidmorphine), MS Contin (slow release morphine), Gabapentin (neuropathic pain)along with paracetamol and ibuprofen.5. Two early doses of morphine were given intravenously (10mg) on 8 July and bysubcutaneous injection (5 mg) on 9 July 2014. The remaining doses were in oralform. Over time the doses and dose frequency of opiate analgesia increased forhis ongoing pain.6. Nursing notes indicate Michael was regularly checked on by nursing staff andthere were no obvious signs of narcotisation and when asleep he was breathingnormally. Subsequent retrospective reviews of the medical records indicatedevidence of deterioration in his respiratory function including low oxygensaturations. Around 04:40 hours on 11 July 2014 Michael was found to beunresponsive and in cardiorespiratory arrest. CPR was performed however hewas unable to be resuscitated and was pronounced deceased at 05:17 hours.Issues for inquest7. Michael’s death was reported to the coroner by Dr Brockett because it wasunexpected and the cause uncertain. An initial review of the medical recordsperformed by Dr Adam Griffin of the Clinical Forensic Medicine Unit consideredthe circumstances of his sudden and unexpected death indicated a probablecontributory factor was the level of opiate medication that was being provided tohim in hospital. Subsequent autopsy examination found the cause of death tobe due to opiate toxicity.8. During the coronial investigation statements were obtained from the admittingphysician, Dr Rodd Brockett and nursing staff. An independent expert reportwas obtained from Dr Charles Denaro who also expressed concern about theprescribing regime of pain medication and in particular the levels of slow releaseand fast acting oral morphine utilised in this case. The hospital also conductedFindings of the inquest into the death of Michael James Calder Page 2a Root Cause Analysis. As a result, a number of systemic recommendationswere made and the Hospital provided details of the implementation of thoserecommendations.9. As there continued to be some uncertainty about the precise circumstanceswhich brought about Michael’s death, a decision was made to hold an inquest.On 15 April 2016 at a pre-inquest hearing, the following issues for the inquestwere determined:a. The findings required by s. 45 (2) of the Coroners Act 2003; namelythe identity of the deceased, when, where and how he died and whatcaused his death.b. The circumstances leading up to the death.c. The appropriateness of the health care provided to the deceased atthe Holy Spirit Northside Private Hospital from his admission on 8 July2014 and up until his death.The following witnesses were called to provide evidence. R.N. Greecezel Goudswaard R.N. Belinda Lewis R.N. Courtney Roach R.N. Sunshine Juan EEN Maryann Meadowfair R.N. Shelly Taylor R.N. Marie Ballinger Dr Rodd Brockett Dr Charles Denaro Dr Peter LavercombeAutopsy results10. A full internal post-mortem examination was conducted by Dr Nadine Forde,Forensic Pathologist. Dr Forde found some mild swelling of the brain but therewas no obvious cause of death. The lungs were heavy and there were moderatepleural effusions and histological evidence of acute aspiration pneumonia.11. Toxicology analysis was performed on admission blood (i.e. blood taken onadmission to the ED and before any medications were provided). Diazepam,sertraline and Ritalin were detected at non-toxic levels in the admission blood.Morphine and other opiates were not detected in admission blood.12. Toxicology was also analysed on post-mortem femoral blood. Post-mortemblood levels found Gabapentin, ibuprofen and paracetamol, Ritalin, sertralineand diazepam in therapeutic or non-toxic ranges. Oxycodone was detected inabove therapeutic but below toxic ranges. Morphine was found well within thelethal range.13. The pathologist noted that morphine levels can be difficult to interpret as thereis overlap between therapeutic and toxic/lethal levels. This is because individualresponses can vary greatly, particularly in the setting of chronic use. However,it was also noted that Michael had no history of regularly taking such medicationand there was no evidence of narcotic analgesia in his blood at the time of hisFindings of the inquest into the death of Michael James Calder Page 3admission. Given his apparent lack of previous exposure to regular narcoticanalgesia the pathologist opined he would have been more susceptible to itseffects than an individual with more regular exposure.14. The pathologist opined that the cause for his headache remains unclear and thepossibility of resolving viral meningitis cannot be excluded, although otherpossibilities may include musculoskeletal pain or migraine. There were noautopsy findings to suggest that death occurred as a result of these.15. There was evidence of acute pneumonia. His initial presentation to hospital didnot fit with that of lower respiratory tract infection. Whilst in hospital there wereno features, including an increase in respiratory rate clinical findings, suggestiveof pneumonia. There was clinical evidence of reduced oxygen saturationsrequiring oxygen therapy at 08:00 hours on 10 July 2014. There were somesmall fragments of foreign material in the lungs and the findings and clinicalhistory are suggestive of an aspiration event, possibly occurring around the timeof this fall in oxygenation.16. The level of morphine fell well within the range considered to be potentiallylethal. Oxycodone is also an opioid analgesic, and whilst the level of oxycodonewas below that considered to be toxic, its actions are similar to that of morphineand the effects would have been additive with the morphine.17. The development of aspiration pneumonia was most likely caused due to theopiate effect causing a reduced level of consciousness impairing his ability toprotect his airways.18. The pathologist considered the death has occurred as a result of opiate toxicity,from both the combined effects of aspiration pneumonia and the immediate toxiceffects of opiates on the central nervous system and respiration.Medical and nursing care provided over 8 to 10 July 201419. Michael had a medical history of anxiety and previous viral meningitis in 2011.In 2009, sleep studies showed him to have severe obstructive sleep apnoeasyndrome for which he received surgical treatment at Holy Spirit NorthsidePrivate Hospital. He was prescribed medications by his GP including Valium(diazepam) and Zoloft (sertraline), medications commonly used (as well as forother conditions) for treatment of anxiety.20. Michael presented to the HSNPH Emergency Centre (ED) at approximately14:40 hours on 8 August 2014. A provisional diagnosis of viral meningitis wasmade. A lumbar puncture was performed, which noted clear fluid and noelevation of white cell count. A CT head scan was normal with no evidence ofintracranial haemorrhage. Other testing was unremarkable. Michael wascommenced on anti-viral medication when he first presented to the ED. He wasgiven analgesia and provided with IV morphine of a total of 10mg over a halfhour period.21. Michael was then admitted to the ward under Dr Rodd Brockett, generalphysician. At the time of admission unusually a Patient History form was notcompleted and hence a question contained on the form as to whether Michaelsuffered or ever suffered from sleep apnoea was not answered. A referral letterfrom the ED was provided and there was a discussion with Dr Brockett. As wellthe ED record was provided. It is apparent the ED is a separate entity to theFindings of the inquest into the death of Michael James Calder Page 4HSNPH. This ED record routinely was not considered by Dr Brockett due to itsdifficulty in being sensibly or easily digested and read. Dr Brockett was notaware of a previous history of sleep apnoea and did not read the entry in the EDrecords that at 19:20 hours in the ED there was an episode when Michael’soxygen saturations plummeted to 79% but rose on rousing.122. Michael arrived from the ED at around 20:15 on 8 July 2014. It is instructive tonote that at the time nursing staff recorded vital signs observations in a ModifiedEarly Warning Score (MEWS) chart. This chart complied with the AustralianCommission of Safety and Quality in Health Care National Standards. The chartis said to be a tool to assist in the recognition of a deteriorating patient.Relevantly, in respect of oxygen saturations the MEWS chart provided asfollows:i. If oxygen saturations fell between 87% and 92% they were toadminister oxygen. If saturation levels continued to fall withincreasing shortness of breath they were to inform the teamleader immediately; ii.If saturation levels fell below 86% they were to apply oxygenand inform the Team Leader who will inform the treatingDoctor;If saturation levels fell below 80% they were to apply oxygeniii. via a non-rebreather bag and institute a MET call. If theycontinue to drop or the patient does not respond to oxygentherapy they are to call a CODE BLUE.23. Endorsed Enrolled Nurse (EEN) Maryann Meadowfair was involved in the careof Michael during the night shifts of 8, 9, 10 July 2014. She first provided astatement to the hospital at 08:20 hours very shortly after the death and herstatement to the coroner was dated 31 July 2014. EEN Meadowfair wassubsequently dismissed from her employment, it seems as a result of whatoccurred. EEN Meadowfair was a very experienced enrolled nurse andunderstood her limitations to practice, particularly regarding medications andthe hospital policies.24. EEN Meadowfair’s shifts commenced at 22:00 hours and concluded at 07:00hours. On each of the night shifts her patients included Michael in bed 19. It isapparent that during the night shift EEN Meadowfair had a patient load of about10 patients. There were two other registered nurses rostered on the ward witha similar patient load. The day and afternoon shifts were rostered somewhatdifferently in that two nurses were allocated 10 patients cared for as a team or‘buddy’ nursing system.25. On the Tuesday of 8 July 2014, EEN Meadowfair recalls Michael had a lot ofheadaches and she gave him pain relief. His neck and back were sore and hestated that his head was pounding. She says in her statement that duringhandover he was admitted for viral meningitis, which he had previously in 2011,and a history of anxiety and sleep apnoea. In her evidence EEN Meadowfairwas less certain about knowledge of the history of sleep apnoea and stated thiswas really a ‘Query?’ about sleep apnoea. R.N. Juan gave evidence that on 9July she asked Michael if he had a history of respiratory difficulties such as sleepapnoea and received a negative response. It is probable that the respiratorydifficulties including the possibility of sleep apnoea were discussed amongst1 This information was not referred to in the referral letterFindings of the inquest into the death of Michael James Calder Page 5nursing staff and it is in this context that EEN Meadowfair’s ‘query’ about sleepapnoea was considered. It is fair to say the history of previous treatment for anddiagnosis of sleep apnoea was not evident to treating staff, including DrBrockett, until after the respiratory arrest.26. It may be important to acknowledge at this point that Michael had previoussurgery to alleviate the symptoms of sleep apnoea at the same hospital. It isapparent that the previous hospital admission records did not becomeimmediately available on the ward as should have occurred.2 As well, it wasconsidered likely that Michael (similarly to other persons receiving thistreatment) may have mistakenly thought the surgery cured him of sleep apnoearather than alleviating some of the symptoms such as snoring. This may havebeen the basis for his negative response to the inquiry by R.N Juan.27. R.N. Greecezel Goudswaard was involved in the afternoon shifts of 9 and 10July 2014 from 14:00 hours until 22:30 hours. She made a note in the progressnotes towards the end of her shift on 9 July 2014 that Mr Calder was alert andcoherent, mobile and self-caring and his observations were stable and he wasafebrile. He continued to make complaints of a severe headache and she notedshe had given him pain relief for this with some effect. She gave him 40mg ofOrdine at 05:15 and says this must have been on the basis that his pain was atthe more severe end. The records note she took a number of observations,which are recorded in the observation chart and provided medication. Hisoxygen saturations were 95% on room air with other vital signs all within normalrange. R.N. Goudswaard said she does not recall any discussions with DrBrockett about Michael’s condition or treatment plan and medications on any ofher shifts. She said some doctors will speak to the nurses or the team leaderwhile others will write the orders up in the chart.28. On the night shift of Wednesday 9 July 2014, EEN Meadowfair thought Michaelseemed a lot brighter although he still had headaches. She made no mention inthe progress notes as to the level of pain and agreed with hindsight it wouldhave been prudent to do so.29. R.N. Courtney Roach was rostered on the morning shift of 10 July 2014commencing at 06:30 hours until 15:00 hours. She recalls she was working witha buddy nurse R.N. Xie Juan . She is uncertain as to whether it was R.N. Juanor herself who administered 40mg OxyContin at 07:15 hours, although hersignature is in the medication book. R.N. Juan recalls it was herself.30. Prior to 07:50 hours R.N. Roach recalls R.N. Juan speaking to her regarding theprescription for Ordine. R.N. Juan was concerned that the order in the chart didnot specify a frequency or maximum dose. Together they noted that the lastdose had been given to him at 04:30 hours and they wanted to check whetherit could be administered third hourly. Hospital policy required that all telephoneorders must be communicated to two nurses. A telephone call was made byR.N. Juan to Dr Brockett and he confirmed it was to be third hourly and shebelieves that R.N .Juan wrote that in the chart and she co-signed. R.N. Juangave Mr Calder another 20mg dose of Ordine at 07:50 hours. R.N. Juan saysshe intentionally kept the dose at the lower end of the ordered range as she was2 The evidence of Ms Ravn is that by interrogating the HSNPH clinical information system it seems theprevious medical records were requested at 09:10 hours on 9 July 2014 and were in the ward by 10:56hours. It remains unclear where the records were kept during 9 and 10 July but they were certainlypresent when Mr Calder was found unresponsive.Findings of the inquest into the death of Michael James Calder Page 6not aware of Mr Calder’s need for or response to pain medication and she notedthat he had also been given OxyContin (slow release) at 07:15 hours.31. R.N. Juan performed observations at 08:00 hours on 10 July. Prior to this shenoted his oxygen saturations were 85% to 88%. She recalls the oxygen probealarmed at 85% when she first placed the probe on his finger but stabilised at88% after a few seconds. She stated she applied oxygen but cannot recallwhether she started with 1-2 L and increased to 3 L, but at 3 L his saturationscame back to 92%. The formal recording of oxygen saturations at 08:00 hourswas 88%. She recalls Mr Calder was surprised when advised that he neededoxygen. She recalls she was also surprised by the reading because clinically heappeared fine. She asked if he had any respiratory problems such as sleepapnoea and he said no. She recalls mentioning to R.N. Roach that the oxygensaturations had been low.32. She returned to Mr Calder’s room to check on his pain relief and to ensure hisoxygen saturations remained acceptable. At 10:00 hours he advised hisheadache was as bad as it had been earlier and she gave him a further full doseof 40mg of Ordine. His oxygen saturations remained acceptable. Later she wentto check on him again after the second dose and he was walking around andhe said the headache had improved a little. She administered a further dose of40mg Ordine at 13:40 hours as he had requested further pain relief. Each timeshe saw Mr Calder on the ward he was speaking clearly and did not seemdrowsy.33. R.N. Roach recorded his observations at 11:30 hours with his temperature 36.9,blood pressure 115/68, pulse 97, respiratory rate 18, oxygen saturations 93%and he was on 2 L of oxygen. She cannot remember the pain score as she didnot record it. It is now her practice to record pain scores for each patient but atthe time her usual practice was to ask but not necessarily record it every time.34. R.N. Roach recalls Michael was awake but tired. He was in pain and wanted theroom dark. She administered his regular midday 1g paracetamol and 400mgibuprofen. She noted that prior to handover Dr Brockett had recently attendedand made new medication orders, so she completed the times when the regularmedication was to be given. She stated it was not unusual for doctors to notspeak to the nurses about changes in medication or treatment and they wouldeither speak to a team leader or write in the progress notes.35. R.N. Greecezel Goudswaard also cared for Michael on the afternoon shift of 10July 2014. R.N. Belinda Lewis was her buddy on the shift. R.N. Lewis tookobservations at 16:30 hours. Michael’s temperature was 37.7, BP 120/72, pulse100, respiratory rate 18 and he was on 2L oxygen via nasal prongs. She did notrecord his oxygen saturations but said with the machine on, it would havealarmed if it went below 90%. He complained of severe pain but she did notrecord it. She gave him 40mg Ordine at 16:45 hours as well as paracetamol andgabapentin at 18:00 hours. She recalls Michael kept taking off his nasal prongsas he found them irritating. He sounded coherent and was not slurring his words.36. R.N. Goudswaard recalls that Michael remained troubled by headaches butwas alert, coherent and conversing appropriately. In her statement she said hedid not appear ‘particularly drowsy’ and was not slurring his words. She wasunable to explain the choice of word ‘particularly’ and re-iterated he was notdrowsy. He did not appear to be in any way confused. She gave Mr Calder MSContin, ibuprofen and Movicol at 20:00 hours. The Doctor had ceasedFindings of the inquest into the death of Michael James Calder Page 7OxyContin earlier that day and replaced it with 80mg MS Contin twice daily. Shegave Mr Calder his first tablet of MS Contin at 20:00 hours. She also gave him400mg ibuprofen and his second dose of gabapentin. She performedobservations at 20:30 hours with temperature 37.1, BP 130/84, pulse 102,respiratory rate 20. She noted there had been a slight rise in his respiratory rateand heart rate but they were within an accepted range and he was not exhibitingany significant symptoms. At no time did Michael show signs of narcotisation.Unfortunately, she did not record his oxygen saturations and whether he wason room air or 2L nasal prongs. There were no oxygen saturation readingsrecorded for two observations and she was unable to say why that was. Sherecalled Michael kept taking his oxygen nasal prongs off and had to remind himto put it back on. She also recalls checking his oxygen saturations and with theoxygen probe on it would have alarmed if they went below 90% and this did notoccur. She noted in the progress notes that his severe headache remained ‘+++’but was unable to explain how this reconciled with the fact she recorded thepain score on the observation chart as ‘0’. She handed over to EEN Meadowfairbut cannot recall the substance of the handover.37. When EEN Meadowfair commenced her shift on 10 July 2014 she recalls thatMr Calder was a lot brighter but still had the headaches and he had been put ondifferent pain medication. She recalls checking on and recording observationsof Mr Calder around midnight. Upon entering his room she recalls he was in adeep sleep and could hear him snoring loudly through the closed door. She wasunsure why the door was closed and presumes he asked for it to be shut. Shecould not recall if she woke Michael. She checked on him again at 02:00 hoursand he was asleep and snoring very softly.38. EEN Meadowfair stated that they were doing hourly roundings but she cannotrecall if she checked in on him in the period between 02:00 and 04:00.EENMeadowfair said it was her practice to place patients on oxygen if theirsaturations went at or below 90%. She agreed the fact she placed him onoxygen was not recorded in the observation charts. At 24:00 she noted thesaturations were 90% on room air but there is no notation anywhere that sheused nasal prongs to introduce oxygen. Her version which was used to completeher statement was recorded within hours of the tragic events and also makesno reference to oxygen being supplied.39. When EEN Meadowfair entered at 04:40 to check on Mr Calder and to do hisobservations, there was no snoring and she thought he looked different. Sheput a light on and noticed he looked pale and she hit the CODE BLUE cardiacarrest buzzer on the wall. She cannot recall the exact timing of events but hasbeen informed the buzzer was hit at 04:41 hours.40. R.N. Marie Ballinger had not been providing primary nursing care for MichaelCalder. She heard the emergency call at around 04:40 hours and immediatelywent to room 19 where EEN Meadowfair had hit the emergency buzzer. Onentering the room she saw EEN Meadowfair using voice commands to MrCalder to determine if he was conscious. He appeared very pale and lifeless.41. R.N. Ballinger commenced CPR. R.N. Shelly Taylor entered the room and R.N.Ballinger instructed her to bring the cardiac arrest trolley. R.N. Ballinger theninitiated cardiac compressions. She inserted a Guedel’s airway to assist withairway management and began using the breathing mask in combination withcardiac compressions. R.N. Taylor then assisted in the resuscitation. Sherecalls hooking up oxygen to the air viva bag. She believes they worked on theFindings of the inquest into the death of Michael James Calder Page 8patient for 30–45 minutes. Dr Brockett was called in as well as the HospitalCoordinator.42. The arrest team from the ICU then attended the ward and began to lead themanagement of the arrest. The nurses then alternated completing cardiaccompressions and performed other duties as instructed. The resuscitationceased at 05:17 hours.43. Resuscitation efforts lasted for more than half an hour when Dr Brockettdeclared Mr Calder deceased.Evidence of Dr Rodd Brockett44. Dr Rodd Brockett is a specialist physician and intensivist. It is important to recordthat at the inquest Dr Brockett provided an emotional apology to Ms Young andthe Calder family and took responsibility for his practice and the treatmentprovided to Michael, which he now acknowledged was wrong. Ms Young verygenerously thanked him for that apology.45. Dr Brockett provided three statements. In his first statement Dr Brockettdescribed the treatment history. At the time he first saw Michael Calder he hadalready been given 5mg of Morphine subcutaneously and was receiving Endone5mg four times a day. His pain was quite severe and his neck ache was alsosevere. He described a slightly improving photophobia. Dr Brockett appears tohave seen Michael Calder on the ward at some time during 9 July 2014 but atime was not specified. At that time the plan was to continue IV antivirals. DrBrockett noted a ++++ headache.46. Dr Brockett stated that he tried to get on top of the pain by ceasing the regularEndone and changing it to OxyContin 40mg twice daily.47. On 10 July 2014 it was noted that the headache had persisted. Dr Brockettappears to have seen Mr Calder around 11:30 hours on 10 July 2014 noting theheadache persisted, chest clear, IV out and to increase analgesia. Dr Brockettincreased the analgesia by giving him 160mg/day of MS Contin in two divideddoses and continuing as needed dose of Ordine, ceasing the OxyContin andstarting some Gabapentin (Neurontin) at 300mg to load him up with intention ofgoing to a lower dose the next day.48. Dr Brockett had no further contact with or about Michael until he was called at04:44 hours on 11 July 2014 by the on duty nurse coordinator who said Michaelwas in asystolic arrest. He attended immediately and noted the efforts at tryingto resuscitate him but it was agreed that after 30 minutes further continuationwould be futile.49. Dr Brockett disagreed with the initial assessment of Dr Griffin in relation to thechart review. He stated that The Australian Medicines Handbook adopts a scalethat the approximate dose equivalent to 10mg of parenteral morphine is 30mgof oral morphine and 15mg of oxycodone.50. Dr Brockett stated that when he first reviewed Michael sometime between 13:00to 17:00 on 9 July 2014 he had received 10mg IV morphine, 5mg subcutaneousand 10mg oxycodone orally. He stated that this meant he had in the preceding24 hours received approximately 40mg Endone with inadequate analgesia andtherefore he doubled the dose to 80mg baseline Endone equivalent (40mg bdFindings of the inquest into the death of Michael James Calder Page 9of OxyContin) and provided 20-40mg oral morphine (3 hourly as required) ontop of the baseline of the OxyContin, paracetamol and ibuprofen.51. When Dr Brockett reviewed Michael the next day between 11:00 to 12:00 hewas still in pain. In the intervening period he had received 180mg oral morphineand 80mg oral oxycodone–equivalent to 300mg of oral morphine or 100mgparenteral morphine. He ceased the OxyContin and continued the paracetamol,ibuprofens and as needed oral morphine order. He prescribed oral sustainedrelease morphine (MS Contin 80mg bd).52. He states that at no point was there any indication that Michael was receivingtoo much morphine equivalent and he did not believe this was the case. Michaelwas noted on the nursing notes to be bright and alert and therefore he felt hewas not affected by narcotics.53. Dr Brockett provided his second statement shortly prior to the inquest and ashort third statement prior to his evidence. Dr Brockett states that he genuinelybelieved he was acting in the best interest of his patient. Mr Calder’s death hascaused him to undertake further self-education and to reflect upon his actions.He states that he has reviewed many medical articles and abstracts relevant tothe issue and this review has clearly brought home to him the complexitiessurrounding the variable absorption rates of oral narcotics, as well as thecomplexities of slow release narcotic preparations. There are conflicts within thejournals about some of those issues. He states that this has brought him starklyto the conclusion that he cannot reliably dose slow release narcotics for acutenonsurgical pain and cannot reliably predict the effects of the narcotics on anindividual. He realises that his practice was wrong.54. He states that he now approaches acute pain management very differently. Heis now following a framework that has been developed following substantialdiscussion at the Hospital’s Morbidity and Mortality meetings. Essentially thetransitioning to sustained release oral or topical narcotics would only occur oncestable on a steady dose of the patient controlled analgesia. The framework issummarised as follows:i. Regular paracetamol if there are no contraindications;ii. Regular non-steroidal anti-inflammatory drug or COX2 inhibitorif appropriate for the type of pain and if there are nocontradictions to the use;iii. Patient-controlled analgesia with either fentanyl or morphine ifacute pain which would be postoperative pain or acute severepain (pain not controlled with doses of oxycodone, or theequivalent of 20 mg/day or less for a patient who is under theage of 85 or over 65 kg, or more than 10 mg/day of oxycodoneif they are less than 65 kg or over the age of 85. This wouldrequire use of intravenous or subcutaneous access and wouldalso tie into the hospital’s use of continuous oximetry;iv. Then it would be recommended to consider anti-elliptic drugs orTri-Cyclic antidepressants as co-analgesics after doing someform of sleep apnoea screening. No co-analgesics should beFindings of the inquest into the death of Michael James Calder Page 10prescribed with neurological effects except by the primaryphysician/Surgeon/anaesthetist;v. Finally, transitioning to sustained release oral or topicalnarcotics would only occur once stable on a steady dose of thepatient controlled analgesia. This is where fentanyl may havecertain advantages because the translation from a fentanyl PCAin terms of hourly use on average across the day to a patch ismuch easier and does not require any mathematical gymnasticswhich OxyContin and MS Contin may.55. Dr Brockett stated that on admission to the ward he was not aware that MrCalder’s oxygen saturation level had dropped to 79 at 19:20 hours on 8 July2014 whilst in the ED, with a respiration rate of 112. Had he been aware of theseentries this would have raised queries to try to understand why the oxygensaturations were so low. He would not have prescribed sustained releasenarcotics and would have reduced the dose level of Ordine to half, butincreasing the frequency.56. Dr Brockett stated that although the full file comes from the Emergency Centrewith a computer printout of the observations, it was not then his usual practiceto go through each and every entry. His primary reference was to the letter ofreferral from the ED with an expectation that if there had been any significantobservations of the patient, that it is recorded and commented on. Dr Brockettstated that now the ED print-out still comes to the ward but there is atranscription of the observations onto a new standard observation form AdultDeterioration Escalation Chart (ADEC), so that this information is readilyavailable in a conventional way.57. Dr Brockett also stated that he was not aware, at the time of his initialconsultation, that Mr Calder had a history of obstructive sleep apnoea. Althoughhe took a medical history, Mr Calder had not disclosed this to him. Dr Brockettstates that this is not a criticism of Mr Calder as whilst taking the medical historyhis questioning style was intended to obtain all relevant information from thepatient, but clearly it did not on this occasion. There was nothing in the hospitalfile or referring letter, which stated that Mr Calder previously had obstructivesleep apnoea. He also did not know that Mr Calder had previously been a patientof the hospital. It also occurred to him that patients who have had surgery forobstructive sleep apnoea, may well think they are cured because they no longersnore. However, such surgery does not in fact cure obstructive sleep apnoea,but rather prevents the noise of snoring. Dr Brockett states he has changed hisquestioning style so as to specifically ask the patient whether they have had anyoperations at all in the past. If he had been aware of the obstructive sleepapnoea this would have drastically changed his approach.58. In relation to communication practices with nursing staff he stated that itcontinued to be difficult to find individual nurses as they are often with otherpatients. Now his practice is to speak to the team leader on the ward. In relationto documenting in progress notes he acknowledges that he should documenthis findings better but stated that as he was the sole person making thedecisions this was basically a recording of his thought processes for futureconsideration by him.59. Dr Brockett stated that he would expect to be told if oxygen saturations wentbelow 91 or 92%.Findings of the inquest into the death of Michael James Calder Page 1160. Dr Brockett remained unsure as to the underlying cause of the headache. Itcould have been a viral infection or post viral.Root Cause Analysis61. The Holy Spirit Northside Private Hospital conducted a Root Cause Analysis(RCA) and this was finalised in January 2015. The HSNPH reviewed the RCAon two further occasions after the receipt of the Autopsy Report and after furtherinterviews were conducted with all staff who provided care to Mr Calder. Thisresulted in a final RCA finalised in April 2015. The RCA was not informed byinformation from the treating doctor, Dr Brockett, as he declined to participate inthe process on advice from his legal medical defence organisation.62. The first RCA identified a failure by night shift nursing staff to recognise andrespond to early signs of clinical deterioration (oxygen saturation levels of 90%at 2400 hours on 10 July 2014) as a factor that may have contributed toMichael’s unexpected death.63. Another possible causal factor was identified that due to the patient complainingof a headache throughout his admission with no other focal neurology, theRegistered Nurses (RN) provided opioids as prescribed by the treatingphysician to manage the patient’s headache, therefore a focused assessmentof pain management was not considered by the RNs, which may havecontributed to the patient’s unexpected death.64. The hospital acknowledged there were system issues identified that the hospitalmanagement team has been actively working on. This included a review ofcurrent clinical practice model to establish escalation process for clinicalobservations undertaken by enrolled nurses. Further as part of the handoverprogram, pain management will be specifically addressed to enable clinical staffto consciously consider or discuss opioid usage.65. The hospital also has met with Mrs Calder’s partner by way of an opendisclosure. It is understood that the hospital dismissed the enrolled nurse whowas the subject of some criticism in failing to escalate the observations to otherregistered nurses on the shift.66. The formal findings and recommendations of the first RCA were as follows:–i. Due to the enrolled nurse not recognising that an oxygensaturation level of 90% constituted clinical deterioration andtherefore did not escalate to a registered nurse for review, thismay have contributed to the unexpected death. It wasrecommended that there be a review of the current clinicalpractice model (PPM) to establish escalation process for clinicalobservations undertaken by Enrolled nurses. The intention wasfor the clinical practice model to clearly articulate howobservations undertaken by and rolled nursing staff are to becommunicated to the team leader/registered nurse forverification and actioned as required. This was to beimplemented by June 2015.Findings of the inquest into the death of Michael James Calder Page 12ii. Due to the patient complaining of a headache with no other focalneurology, the staff provided opioids as prescribed by thetreating physician to manage the headache, therefore a focusedassessment of pain management was not considered, whichmay have contributed to the unexpected death. It wasrecommended that as part of the SHARED handover program,pain management will be specifically addressed under section“A” (assessment) to enable clinical staff to consciously consideror discuss opioid usage. The intention was for existing tools forusing hand over to reflect that pain management will form partof the discussion held during clinical handover. There were twothe clinical handover audits commencing February 2015.iii. As a lesson learnt it was noted that during the RCA review, itwas determined that the current method of recording clinicalobservations in the Brisbane Northside Emergency Centre wasnot in accordance with Standard 9 of the National Safety andQuality Health Care Standards and therefore criticaldeterioration is not observable using an improved “track andtrigger” escalation chart. It was recommended that the use ofthe HSNPH Adult Deterioration Escalation Chart form within theBrisbane Northside emergency Centre to replace the existingobservation recording process (which is electronic using MEDTECH).iv. Other factors identified including that staff did not administeroxygen when oxygen level fell below 92%. The policy was toapply oxygen as per MEWS form. Staff were also unaware ofpatient history of sleep apnoea. The staff did not recognise thepatient had deteriorated and therefore did not escalate to TeamLeader or senior nurse.67. The Final RCA had the benefit of the Autopsy Report and findings. The RCAformal findings were as follows:i. Due to current processes for monitoring and managingmandatory training, mandatory competency and performanceappraisals, the identification of competency issues with staff, inparticular permanent night staff, were not identified. This mayhave contributed to an enrolled nurse working on night shift witha knowledge deficit in recognising early signs of clinicaldeterioration (oxygen saturation levels of 90%), which may havecontributed to the patient’s unexpected death. It wasrecommended that there be a review of current mandatorytraining/competency/performance appraisal systems to ensuregood governance to manage the clinical risk for monitoring andmanaging staff compliance with expected outcomes. The RCAreport noted this has now been completed.ii. Due to an informal professional practice model that did nothighlight the scope of clinical practice for the R.N./EN/TeamLeader and role responsibilities, there was no supervision of theEN and the decreased oxygen saturation levels at midnight wasFindings of the inquest into the death of Michael James Calder Page 13not escalated to the R.N. for review which may have contributedto the patient’s unexpected death. There was a recommendationfor review of current professional practice model and aProfessional Practice Manager was to be employed to developan action plan to provide an overarching framework for nurses.It was noted that this was completed.iii. Due to ward culture for clinical handover not including all nursesdiscussing all patients at the same time, the RNs were onlyaware of their own patient load and status history (which did notinclude this patient). This may have contributed to nosupervision of the Enrolled Nurse practice on night duty and thedecreased oxygen saturations at midnight was not escalated tothe RN for review, which may have contributed to the patient’sunexpected death. It was recommended there be a review ofcurrent handover practices in all clinical areas to establishguidelines for compliance with the National Standard. Theseefforts were ongoing.iv. Due to the patient complaining of a headache throughout hisadmission with no focal neurology, the RNs provided opioids asprescribed by the treating physician to manage the patient’sheadache, therefore a focused assessment of painmanagement was not considered by the RNs, which may havecontributed to the patient’s unexpected death. It wasrecommended that as part of the SHARED handover program,pain management will be specifically addressed under section“A” (assessment) and “R” (risk) to enable clinical staff toconsciously consider or discuss opioid usage. This aspect of therecommendations has also been completed.68. The RCA also made note of a number of other lessons learnt. This had resultedin the adoption of a new Adult Deterioration Escalation Chart (ADEC), and theadoption of clear guidelines on Rounding for all patients on all shifts. As wellthere was a broad review of current processes and practices surrounding themanagement of the deteriorating patient, review of processes for painassessment including opioid management and review of processes for thetaking of patient history forms.69. The Quality and Risk Manager of HSNPH, RN Donna Ravn also provided astatement detailing improvements made since the death of Mr Calder.70. Given there was some confusion as to who the team leader was on the nightshift of 10 July 2014 there has been an emphasis on documenting thisinformation on daily staffing sheets and allocation boards located in all nursingstations. Ms Ravn also advised that enrolled nurses are no longer rostered onnight shifts.71. The Adult Deterioration Escalation Chart (ADEC) has now replaced the ModifiedEarly Warning System (MEWS) observation chart although both were incompliance with the National Standards. ADEC provides greater ease of use,and clarity around required actions in response to observations that fall within acoloured trigger zone. When patients are admitted via the Emergency Centre, aset of observations are recorded on the ADEC chart so ward staff can clearlysee what the most recent observations are. The Recognising and RespondingFindings of the inquest into the death of Michael James Calder Page 14to Clinical Deterioration Policy now includes clear guidelines for appropriateapplication of oxygen therapy. A stand-alone policy titled Oxygen TherapyGuidelines has also been introduced to provide greater clarity regarding theappropriate use of oxygen therapy. The hospital has purchased a fleet of Nellcorcontinuous monitoring machines, which accurately monitor and measureoxygen desaturation episodes.72. In relation to handovers the team leader for each shift receives a handover fromthe team leader on the previous shift. All nurses on the oncoming shift nowreceive a bedside handover for all patients allocated to their care on the next.Previously this took place at the nurse’s station or in the corridor outside apatient’s room. Pain management has become a much greater focus inhandover discussions. The SHARED handover templates have been updatedto specifically include flagging of respiratory risks, including sleep apnoea oroxygen therapy. Monthly audits including handover processes are conducted.Patient Communication Boards located in each patient room updated each shift.While these boards were in use prior to Mr Calder’s death they have beenredesigned to make them more focused on patient collaboration.73. Each clinical ward now has a ward educator present for eight shifts per fortnightto provide an opportunity for the nurse educator to undertake any relevantmandatory training, assessments and performance appraisal. Permanent nightstaff are now required to work a minimum of four weeks per year on day shift toprovide them with the opportunity to participate in ongoing professionaldevelopment with the nurse educator. Further policies have been introduced tomanage the process for ensuring staff competency through mandatorycompletion of performance appraisal and mandatory training programs by setdates.74. R.N. Courtney Roach provided evidence that a Nellcor machine is now on theward which attaches to a patient’s finger and continuously monitors oxygensaturations and pulse. It will automatically alarm when certain parameters areexceeded. She believes it is below 90% oxygen saturations and around fiftyfour pulse. It is a requirement that these are used for all patients on patientcontrolled analgesia and an option for use by other patients if there are concernsfor any reason. She also states that the Adult Deterioration Escalation Chart hasreplaced the previous observation chart and provides much better guidance onwhat to do with observations that fall within the shaded areas. The Nurse UnitManager has been active in ensuring staff are diligent in recording allobservations including pain scores. Nurses now perform SHARED (situation,history, assessment, risk, expectation, documentation) handovers at thebedside referring to the chart. There are also information boards at the end ofthe patient’s bed to get updated around handover. Other nursing staff advisedthe inquest on a similar basis. RN Goudswaard for instance confirmed thechanges to handover practices which now also involved the patient; that theobservation chart has improved and highlighted a number of things and actionsnurses have to take. There are a number of steps nurses can take where apatient is on pain relief and if they think the patient needs more observations;there was continuous monitoring if a patient comes from recovery and is onPCA; there is floating staff at the hospital to assist when the ward is busy; anda nurse educator is on the ward twice a month providing good continuingknowledge and clinical understanding.75. It is apparent substantial compliance and knowledge of the outcome ofrecommendations has been achieved.Findings of the inquest into the death of Michael James Calder Page 15Expert review by Dr Charles Denaro76. Dr Charles Denaro is a Consultant Physician and Clinical Pharmacologist andthe Director of Internal Medicine and Aged Care at the Royal Brisbane andWomen’s Hospital.77. Dr Denaro opined that he did not believe that the investigation, clinicalmanagement and prescribing practices were appropriate. He believed moreaction was required for the 24 hour care of this patient and he also believed thatthe opiate dosing was inappropriate.78. Dr Denaro stated it was important to note that the patient was opiate naive. DrDenaro also noted the patient was given a mixture of intravenous morphine,subcutaneous morphine, oral morphine, slow release morphine, oxycodone andslow release oxycodone. This made the interpretation of the total effect of thesenarcotics on the patient complex, but it could be teased out.79. Dr Denaro stated it was important to appreciate that there is individual variationwith the body’s handling of these medications and that averages have beenused in various tables in the literature to compare one narcotic with another andone preparation with another. There is also variation in the literature betweendifferent tables used to convert one narcotic preparation to another. Becauseof these uncertainties in both pharmacokinetics and pharmacodynamics, thedosing of opiates in non-terminal or non-cancer pain should be conservative.The Australian Medicines Handbook states to use small dose increments, asthe dose required may vary more than 10-fold between patients of similar age,irrespective of weight.80. Dr Denaro also noted that on average, oral morphine has a bioavailability rangeof from 15% to 60%, but on average only one third is absorbed and reaches thesystemic circulation. On average the bioavailability of oxycodone is 50%, whichmeans that approximately half of the dose is absorbed into the systemcirculation and is then equivalent to morphine potency. Thus oral oxycodone ismore potent than oral morphine.81. Dr Denaro then set out a detailed table of the narcotic exposure of Mr Calderover the days commencing 15:10 hours on 8 July 2014 to 21:00 hours on 10July 2014.This is reproduced below.82. Dr Denaro opined that over the total of 53.8 hours Mr Calder received by way oforal morphine equivalent 535mg to a maximum of 595mg. The Parental(intravenous) morphine equivalent was 178.3mg to a maximum of 198.3. DrDenaro stated that there can be no doubt the doses of opiates in this opiatenaive patient were extremely large over a time period of just over two days.83. Dr Denaro stated that conventionally to control pain the opiate or narcotic doseescalation from one day to the next is conservative especially in non-cancerpain. It is often recommended that there should only be an increase in dose overthe previous day by 25-50%. This convention is stated in the approved productinformation for slow release oxycodone (OxyContin). Dr Denaro stated thatpersonally he has never escalated narcotic doses in this fashion for pain in anon-terminal condition.Findings of the inquest into the death of Michael James Calder Page 1684. Dr Denaro also stated the management of break through pain was anotheraspect of concern. The patient was also given gabapentin on 10 July 2014,which medication itself has sedative properties and would have added to thesedating properties of the opiates.85. The next factor to consider was the patient’s periods of well documentedhypoxaemia. It is well established that opiate medications worsen obstructivesleep apnoea. In the emergency department, after being given 10mg of IVmorphine the patient oxygen saturations decreased to 79%. This is very low andrequired oxygen supplementation. The most likely situation is that the sedationcaused by the morphine worsened his partially treated obstructive sleep apnoeaFindings of the inquest into the death of Michael James Calder Page 17and blocked his airway. Oxygen saturations returned to thenormal after oxygensupplementation.86. During the morning of 10 July the patient’s oxygen saturations were recorded at91% at 04:00 hours and 88% at 08:00 hours and required supplemental oxygen.At 11:30 his oxygen saturations were 93% and at 24:00 hours 90%. Dr Denarosaid these levels are quite low and could be consistent with excessive sedationcausing worsening obstructive sleep apnoea or aspiration.87. Dr Denaro noted there are no notes in the medical records that indicate thetreating physician noticed these periods of hypoxaemia nor the requirement foroxygen supplementation nor any indication of what might be the possible cause.The time of consultation by the treating physician on 10 July is not indicated inthe chart, however the treating doctor should have been aware of the periods oflow oxygen saturations that occurred in the early morning of that day. The nursewho was looking after the patient stated the patient was snoring heavily on thenight of 10 July and was later snoring softly and one of the possible and likelyexplanations, given the toxicology results, is that the patient by then was heavilysedated by the narcotics and had a depressed respiratory drive.88. The combination of large doses of narcotics and episodes of intermittenthypoxaemia should have alerted the clinician that the patient required very closeobservation, ideally not in a single room with the door closed and these concernsshould have been clearly articulated to the nursing staff looking after the patientovernight.89. Lastly, the cause of the patient’s headache and its persistence must beconsidered. It does seem that initially the patient had symptoms suggestive ofmeningism and that this was an inflammatory illness. The persistence of theheadache, which seemingly required large doses of opiates, might suggestalternative diagnoses need to be considered. One common cause of persistentheadache in this situation is the post-lumbar puncture headache and theemergency notes do document that the patient’s headache was worse after thelumbar puncture and improved lying down. Dr Denaro considered it a possibilitybut it should always be considered in this clinical situation and a post-lumbarpuncture headache requires other management options to ameliorate the pain.90. In summary, Dr Denaro believed the patient’s opiate prescribing was excessivefor an opiate naive patient and this prescribing could very well have caused thispatient’s demise. He believes there is some evidence to suggest the patient hadpartially treated obstructive sleep apnoea, which was made worse by thesedative properties of the opiates and this may have been an extra factorcontributing to the patient’s death. In his opinion both issues should have beenrecognised by the treating clinician and action taken place to prevent the finaloutcome.Expert report by Dr Peter Lavercombe91. Dr Lavercombe also provided a report at the request of the legal representativesof Dr Brockett. Dr Lavercombe is an experienced Intensive Care Specialist andGeneral Physician.92. Essentially the opinions of Dr Denaro and Dr Lavercombe did not differ, otherthan their approach to pain management is dependent upon the situation inwhich they were working. Dr Lavercombe works with acute pain in an ICUFindings of the inquest into the death of Michael James Calder Page 18setting with constant monitoring and nursing, whilst Dr Denaro deals more withchronic pain in a general ward where there is less expertise and monitoring.93. Dr Denaro starts with low pain relief medication and works in incrementsconservatively until adequate analgesia is achieved. Dr Lavercombe stated thisis sound medical practice particularly where the pain is, or is likely to be chronic.Dr Lavercombe stated that he deals extensively with acute pain, which is timelimited and related to a specific insult, for example, surgery, and will bedecrementing over time.94. Hence, Dr Lavercombe stated he would use large early doses through standardnon-narcotic multi-modal therapy and use a Patient Controlled Analgesia device(PCA) with short acting narcotics, fentanyl or morphine, to allow the patient todetermine the appropriate levels of narcotic. The PCA is programmed to delivera safe maximum for each individual patient.95. Dr Lavercombe stated his practice was not to switch between the various formsof oral narcotics because of the significant differences in both the bioavailabilityand bioequivalence.96. Dr Lavercombe stated that he considered Dr Brockett’s clinical decisionregarding analgesia on 8 and most of 9 July 2014 to be reasonable, exceptingthe use of large doses of oral morphine. He stated that even using his practiceof large early doses, this was more than he would use without close observationand continuous pulse oximetry.97. He stated the clinical decision to commence slow-release oxycodone on thenight of 9 July 2014, in combination with the larger dose of as-requiredmedication, risked the short-acting narcotic being given before the slow-releasenarcotic had reached its maximum effect, thus causing an accumulation.98. Dr Lavercombe stated that the change to slow-release morphine on the night of10 July 2014 was problematic given the dose of slow-release oxycodone in themorning and the continuation of as-required doses of morphine. He stated therewas no doubt that the doses of morphine administered were excessive,compounded by the use of combinations of short-acting narcotics and differentforms of long-acting narcotic with differences in bioavailability andbioequivalence. Dr Lavercombe stated the fact that the method of analgesia isnot of the conventional start-low-and-titrate-up approach is of less concern, thanthe total dose employed, and the various formulations used in a ward situationwhere monitoring is not as rigorous as in an intensive care unit.99. Dr Lavercombe stated the oxygen saturation reading of 90% at midnight on 10July was a significant ‘trigger point’, being indicative of a point where there wasa significant drop in the oxyhaemoglobin disassociation curve and indicating acritical point at which inadequate amounts of oxygen were being received by thepatient.100. Dr Lavercombe agreed that the framework now being adopted by Dr Brockett isan appropriate framework for management of pain that is expected to be timelimited, particularly if combined with close observation and pulse oximetry, whensignificant doses of narcotics are employed. The conventional approach ofstarting with a low dose and titrating up remained superior for the treatment ofpain that is chronic or likely to be chronic.Findings of the inquest into the death of Michael James Calder Page 19 101.Dr Denaro also agreed the framework was fine if there was close observationand expertise. 102. Dr Denaro opined that the three factors that are likely to have resulted in thedeterioration was a combination of sleep apnoea, opioid increase andintroduction of gabapentin. Dr Lavercombe also considered the deteriorationwas a combination of factors of sleep apnoea with the slow release OxyContin,oral Ordine (morphine) and gabapentin peaking half-lives and accumulating atthe same time around late evening to midnight and 1pm.Conclusions on the issues103. In reaching my conclusions it should be kept in mind that a coroner must notinclude in the findings or any comments or recommendations, statements thata person is or may be guilty of an offence or is or may be civilly liable forsomething. The focus is on discovering what happened, not on ascribing guilt,attributing blame or apportioning liability. The purpose is to inform the family andthe public of how the deaths occurred with a view to reducing the likelihood ofsimilar deaths. 104.If, from information obtained at an inquest or during the investigation, a coronerreasonably believes that the information may cause a disciplinary body for a person’s profession or trade to inquire into or take steps in relation to theperson’s conduct, then the coroner may give that information to that body.105. The impact of hindsight bias and affected bias must also be considered whenanalysing the evidence. Hindsight bias and affected bias can occur where afteran event has occurred, particularly where the outcome is serious, there is aninclination to see the event as predictable, despite there being few objectivefacts to support its prediction.106. It is also my experience that in most health care related adverse events thereare usually multifactorial issues at play and a combination of system and humanerrors. Poor communication, poor documentation and a lack of safeguards canresult in poor decisions being made. Some of those factors are evident in thiscase and these resulted in a number of missed opportunities to diagnose thedeterioration in condition being suffered by Michael Calder.107. This case also emphasised the importance of systems being in place torecognise and manage a deteriorating patient. It has been recognised thatwarning signs of clinical deterioration are not always identified or acted upon.As a result there is a specific component for Recognising and Responding toClinical Deterioration contained in Standard 9 of The National Safety and QualityHealth Service Standards. As the Standard states, serious adverse events areoften preceded by observable physiological and clinical abnormalities and earlyidentification of deterioration may improve outcomes and lessen the interventionrequired to stabilise the patient if his condition deteriorates in hospital.108. This case also emphasised the importance of systems being in place to promotethe dissemination of accurate and relevant information at clinical handovers.Handovers have long been seen to be high risk areas for patient safety andsignificant work has been conducted at high levels to improve handoversystems.3As a result there is a specific component for Clinical Handover3 As an example see the OSSIE Guide to Clinical Handover Improvement developed by theAustralian Commission on Safety and Quality in Healthcare.Findings of the inquest into the death of Michael James Calder Page 20contained in Standard 6 of The National Safety and Quality Health ServiceStandards. As the Standard states, clinical communication problems are a majorcontributing factor in 70% of hospital sentinel events. Poor or absent clinicalhandover can have extremely serious consequences and can result in a delayin diagnosis or treatment. 109.It is in the context of all these factors that I draw my conclusions on the issuesfor determination. Cause of death110. The cause of death, consistent with the clinical records, expert evidence andthe opinion of Dr Forde, the Forensic Pathologist, is that Michael died due toopiate toxicity. Michael was found to have a morphine level in his blood wellwithin the range considered to be potentially lethal particularly combined withthe presence of oxycodone and gabapentin. These medications cause areduced level of consciousness thus impairing Michael’s ability to protect hisairways, particularly with the history of obstructive sleep apnoea. This resultedin aspiration pneumonia. As well, there would have been immediate toxic effectsof opiates on the central nervous system and respiration.111. The cause of Michael’s headache was not able to be established at autopsy andthere is no consensus as to the cause based on the opinions of the treatingphysician and independent experts.Appropriateness of the health care provided112. The evidence gathered at the inquest and during the investigation have in myview clarified one of the aspects about Michael’s clinical presentation which wasconfounding. It was difficult to understand how Michael could die from opiatetoxicity when Michael was not exhibiting overt signs of narcotisation in that heappeared to be alert, coherent and not drowsy. It is accepted nursing staff werenot necessarily on the look-out for these signs, but it is more likely than not theywould have been noted if they were present.113. There was certainly evidence of reduced oxygen saturations throughout theadmission. These appear to have been generally observed by nursing staff andMichael was provided oxygen which brought them back to an acceptable level.Unfortunately, there were a number of occasions when nurses did not recordMichael’s pain scores and reports of pain nor his oxygen saturation levels andactions taken in response. This meant staff did not have a clear picture of theprogression of his pain and oxygen saturation levels.114. EEN Meadowfair did record his oxygen levels to be at 90% at midnight on 10July. She did not record what action was taken, including if she provided oxygen.She said that was her practice as required under the MEWS chart guidelines,but there is no mention of her taking that action in the medical records nor wasthis recorded in her statement taken within hours of the death. Michael wassnoring heavily at the time. She makes no reference to waking him. In my viewit is more likely than not that EEN Meadowfair did not apply oxygen at that time. 115.This moment was a critical time according to the findings of the RCA and theopinions of the experts. Dr Lavercombe described it as a ‘trigger point’. Dr Denaro agrees although he also believes there were earlier concerns on themorning of 10 July when oxygen saturations dropped to 88%.Findings of the inquest into the death of Michael James Calder Page 21116. What was significant is that it was at this time that EEN Meadowfair heardMichael snoring heavily through the closed door to his room. Two hours later heis heard to be snoring softly. Dr Denaro stated he would not expect a nurse toappreciate the significance of this change. Dr Denaro and Dr Lavercombe areboth of the view that the slow release OxyContin, oral Ordine (morphine) andgabapentin were peaking at about midnight to 1pm. The totality of this evidenceconfirms that Michael was at this time from midnight to 2pm heavily sedated andwas experiencing depressed respiratory drive. He subsequently passed awayin the next short period of time.117. What brought Michael to this point was the regime of opiate medicationsprescribed by Dr Brockett, which regime Dr Brockett now acknowledges was awrong practice. Accepting there may be a difference of approach as to startinglow and incrementing up or starting high and incrementing down, the consensusof the independent expert opinions was the level of opiate medications waslarger than either expert would prescribe. This was also compounded by the factMichael was on a ward and was thus not being constantly or frequentlymonitored. His condition was not assisted by the fact that he was most likely notprovided oxygen supplementation at that critical time around midnight.118. As well, it is evident there was dearth of communication between Dr Brockettand the nurses.4 There is really no evidence to suggest the basis of thetreatment plan was discussed by Dr Brockett with nursing staff. Dr Brockett hasno clear recollection of speaking to nursing staff specifically about Michael andno nurse recalls such a conversation. Dr Brockett did not have a nurse or teamleader with him on his ward rounds. He wrote brief entries in the progress notes.He acknowledges his notes could be better but it is significant he consideredthey were mainly for himself for reference and not for nursing staff. Dr Brockettwrote up medication orders and changes and these were appropriately attendedto by nursing staff but otherwise his notes did not impart any useful informationfor nurses to consider about the treatment plan or that they should be on anyspecial alert or to monitor Michael more often.119. The reason for this is Dr Brockett did not consider Michael was particularlyunwell. His vital signs observations were all within normal range other than someof the oxygen saturations. At the time Dr Brockett considered theanalgesic/opioid medication regime being adopted was an appropriate one andhe certainly did not expect Michael to be at risk of a life threatening event. Henow realises his approach was wrong.120. If there had been a discussion with nursing staff or clear instructions were notedin the records, this may have meant nursing staff were more alert to and awareof the signs to look for in a patient on this regime of opiate analgesia. Thisinformation could have been then handed over to oncoming staff. At the timehowever, nursing staff were simply administering medications that had beenprescribed. They appear to have provided PRN medication utilising appropriatediscretion. The independent experts agreed that it would have been beyond theexpected knowledge of nursing staff to understand the complexities of themedication regime being adopted. As identified in the RCA, there could have4 A not uncommon situation reflecting an educational/cultural divide between medical practitioners andnurses generally which is not confined to HSNPH and which has been the subject of much commentand deliberation in the medical literature and medical/hospital authorities both within Australia andinternationally.Findings of the inquest into the death of Michael James Calder Page 22been a more focussed assessment of the pain management provided to promptstaff to consciously consider the opioid treatment plan.121. It is unclear if this would have made a difference, but EEN Meadowfair may havebeen prompted to express concerns about the low oxygen saturations andsnoring she observed at midnight on 10 July 2016. She may have consultedwith a more senior RN. She would no doubt have been more vigilant in recordingwhat she did in response and more than likely to have applied oxygensupplementation. In fairness to her, she was not so informed.122. Although Dr Brockett and Drs Denaro and Lavercombe consider they wouldhave been expected to have been called when oxygen saturations went below92%, that is not the instruction that guided nurses according to the MEWS tool,which also did not alert staff to conduct closer observations.5 As well there wasno specific instruction from Dr Brockett to do so. 123.The evidence does not suggest that nursing staff felt they could not contact DrBrockett if there was a problem, as R.N.s Juan and Roach called Dr Brockett on 10 July concerning the frequency of administering Ordine. Rather thecommunication between Dr Brockett to nursing staff was lacking. It seems tosome extent this has been improved as team leaders now carry deck phonesso that they can be contacted by doctors after the ward rounds or at any othertime to discuss ongoing management of a patient.Findings required by s. 45Identity of the deceased – Michael James CalderHow he died – Michael came into the Holy Spirit Northside Hospitalfor management of and treatment of headache pain.He had previously been treated for ObstructiveSleep Apnoea at the same hospital but this was notknown by the treating physician. Michael received acomplex regime of analgesia includingsubcutaneous morphine, oxycodone, Ordine (liquidmorphine), MS Contin (slow release morphine),Gabapentin (neuropathic pain) along withparacetamol and ibuprofen. The medication regimeadopted large doses of morphine based medicationin both slow release and liquid form. During theadmission there were critical moments in time whenMichael’s oxygen saturations were low, indicative ofsomeone who was experiencing an impairment inability to protect his airways. The correlationbetween the medications provided and the episodesof hypoxaemia was not recognised by the treatingdoctor or nursing staff. At some point aroundmidnight on 10/11 July 2014 a combination of factorsbeing that of sleep apnoea and with theaccumulation of slow release OxyContin, oral Ordine(morphine) and gabapentin peaking at about the5 Under the new ADEC chart a similar instruction applies and would not prompt a call to adoctor on this ground alone but would prompt a call to the RN in charge.Findings of the inquest into the death of Michael James Calder Page 23same time, resulted in an episode of aspiration andrespiratory depression to which Michael succumbed.Place of death – Holy Spirit Northside Hospital, Rode RoadChermsideDate of death– 11 July 2014Cause of death – 1(a) Opiate toxicityComments and recommendationsI have noted in my finding the RCA recommendations made and the efforts by thehospital to implement them. Drs Denaro and Lavercombe agree the improvements thathave been implemented are comprehensive and address the issues which were madeevident in reviewing the circumstances of Mr Calder’s death.For that reason, I do not believe it is necessary to make any further recommendationsfor implementation by the hospital. Counsel Assisting Ms Jarvis commented that theremay be additional benefit in the Hospital taking steps to ensure the strengthenedcommunications between nurses that has been put in place should also extend tovisiting medical officers and nursing staff. I agree with that sentiment but it is a two waystreet and this would be dependent on the visiting medical officers also contributing tothat change.Dr Brockett has clearly reflected on his part in the circumstances of Michael’s death,accepts his medication regime was wrong and has instituted a framework for futureapproaches to pain management. Dr Lavercombe said the framework is essentiallyhow he approaches acute pain management. In that regard I also do not consider afurther recommendation needs to be made.There does remain the issue of referral of treating nurses and Dr Brockett to theirrespective disciplinary bodies. There was no submission made that I should considera referral and after hearing the evidence I do not consider any specific referral needsto be made by me.I am aware the circumstances of this case have been the subject of a complaint to theOffice of Health Ombudsman (OHO) and our respective offices have been incommunication. There has been an exchange of information in accordance with aMemorandum of Understanding between our offices. Indeed officers from OHOattended at least part of the inquest. In the normal course of events a copy of myfindings will be sent to the Health Ombudsman for any further action it deems fit. Thatwill be the course of action I take.I close the inquest.John LockDeputy State CoronerBrisbane2 September 2016