Coronial Findings 2018

Update provided by THS South 14 October 2022

In relation to recommendation 1 - Rejected

(1) This recommendation seeks to avoid the problem of post mortem redistribution by taking multiple blood samples immediately following and for 72 hours after death. The mortuary service only operates 7.30am to 4.00pm. It would require a coronial order to draw PM blood prior to the autopsy implementation is not practical at this stage. Furthermore, there is a long standing issue in relation to retention of ante mortem admission blood samples in overdoses that die. Blood samples tend to be discarded at around day 7-10. If an overdose case dies after that time then there are no samples for toxicology to analyse.

Updated response provided by THS South 14 October 2022

A statewide Inter-Hospital Transfer policy along with a time critical patient transfer policy has been implemented to support necessary system changes.

Updated response provided by THS South 14 October 2022

Recommendation (1)

The RHH has switched from using the FRAT to the Falls Assessment and Management Plan (FAMP). The rollout of the Falls Assessment and Management Plan (FAMP) to other areas within the THS has continued with the roll out and implementation within the RHH, Repatriation Centre inpatient units, community nursing services and district hospitals. This has extended to a Statewide rollout which has commenced in the north and northwest of the State. The rollout is supported by the senior nursing staff in the areas, allied health and Clinical Nurse Educators. The completion of the charts within the areas is monitored by the staff on the units through monthly' point of care' audits and monthly review of their data. This data is available to the senior executives and the Falls Minimisation Action Group as part of ongoing quality improvement and patient safety monitoring which includes falls rates and severity of injuries. The Falls Minimisation Action Group has also introduced a post fall safety huddle where the team and the patient discuss their recent fall and review strategies in place and recommend new actions if required to prevent further falls. Post fall monitoring of the patient through a post fall clinical pathway has also been adopted across Hospitals South to ensure patients that have had a fall receive medical and nursing clinical review of their condition with frequent observations, and CT scan if a head strike has occurred. The observations and standard of care required post a fall is standardised and any deterioration or review required is provided in a timely manner. Patient and family education is included to prevent falls on the wards and information is provided to the patient during their stay on admission and on discharge.

Recommendation (2)

Direct observation of patients at risk of falling is one strategy in the prevention of falls. The FAMP identifies patients at risk of falling through risk factors such as history of previous fall, unsteady gait, visually impaired, on 4 or more medications and confusion for example. The actions to alleviate or reduce these risks are listed beside the risk identified, and the nurse needs to date and sign that the action has occurred. On the back of the form is a management plan for the patient with communication, environmental, equipment and other care strategies listed. If implemented these need to be signed and dated. Observation is one strategy, and this can be frequent rounding and surveillance by nursing staff every 15 - 30 minutes for example, supervision during toileting and hygiene, mobilisation, or patient safety observers if the nurse's clinical judgement is that they need 1:1 supervision for a period of time, till they are stablised. Bed/ chair check alarms are put in place if the patient is impulsive, confused or cognitively impaired and is unable to use a call bell for assistance. The Falls Minimisation Action Group has encouraged units where able to incorporate the bed/ chair check alarm into the call bell system. Beds with inbuilt bed alarms are also being reviewed for future purchase in some areas following evaluation of their use. Other strategies mentioned in 2019 have continued with close supervision by moving patients close to the nurse's station, referral to Allied Health for review.

Recommendation (3)

As outlined above audits occur monthly on the inpatient units, with the units that do not meet the target on the audit rating supported by CNEs and other senior staff within Q&PS to undertake quality improvement projects to improve their practice. These results are available to the Hospitals South stream executives for further support if required to meet the accepted standard. The Falls Action Group reviews the overall Hospitals South results monthly at their meeting and if these are low new initiatives are discussed and where appropriate may be developed to improve practice to meet the Australian Commission of Safety and Quality in Health Care Standards. These strategies are outlined in a Hospitals South- Preventing Falls and Harm from Falls Protocol.

Recommendation (4)

The FAMP tool has been rolled out with education and tools for staff. There is a Falls Prevention and Management Plan developed for each patient as part of the FAMP tool. This is individualised for all patients and their risk factors. Prior to this, only those patients identified as high risk had individualised plans. The FAMP is also one tool in the Comprehensive Assessment of patients within RHH and will be incorporated into an overall Comprehensive Care Plan for all patients following a recent trial.  Patients that are identified at risk of falls - an Falls Alert can be placed on their file that is current for their present and future admissions if required. There is now only one Falls Alert rather than the two previous versions.  This alerts staff to those patients at risk of falling in all care settings. As mentioned earlier the Post Fall Clinical Pathway, Post Fall safety Huddle and regular auditing of charts have been introduced to provide appropriate patient strategies for the patient to prevent falls and serious harm from falls. Serious falls that cause head injuries or fractures or other serious harm are then investigated either by London Protocol or Root Cause analysis so that any recommendations for improvement can be implemented to prevent further incidents.

Recommmendation (5)

All requests from the Coroner need to come through the RHH Medico-Legal office with endeavours to meet the Coroner's requested timelines

Response from Marine and Safety Tasmania (MAST)  16 July 2019

• Boatwise articles, MAST TV with expert Dr David Smart into CO monitors, facebook, education nights,

Response from Marine and Safety Tasmania (MAST)  16 July 2019

• Boatwise articles, MAST TV with expert Dr David Smart into CO monitors, facebook, education nights,