Western Australian State Coroner Fogliani made a number of recommendations in the inquest into the death of Ashleigh Hunter, a 26-year-old woman who died of meningococcaemia, aimed at closing the gap between ambulance officers and hospitals when managing and monitoring acute patients who are ramped prior to entry into the emergency department. However, the facts of this inquest illustrate some of the potential pitfalls for emergency medicine practitioners when assessing and managing acute patients both on the ramp and within the emergency department.
By way of summary, Ms Ashleigh Hunter died at Royal Perth Hospital on the afternoon of 27 December 2019 from a meningococcal infection after being taken there by ambulance at approximately 1.16 pm and then waiting outside the ED, first on the Ramp and then in the ABay, for approximately one hour. The ED was overcrowded that day, and the hospital had implemented the ED Capacity Procedure.
Ambulance ramping and the fragmentation of care
It was noted that at the time of Ms Hunter’s presentation, she went through a number of handovers. The Coroner heard evidence that each handover comes with a concomitant communication risk – being a risk of deterioration in the quality of information passed on from ambulance officers and/or clinicians to the next person. That risk was heightened where the handover is not complete, or where they are handed over to a temporary clinician or placed in a holding space.
This reflects a systemic problem within emergency departments which falls outside the control of individual practitioners, but awareness and recognition of this risk can assist a clinician to amend their practice to either seek a more complete handover or to bring independence and vigour to each fresh assessment of a patient.
The focus on illicit drugs.
The inquest involved inquiry into whether Ms Hunter’s use of illicit drugs impacted on her care and whether there may have been an associated cognitive bias that clouded the assessment of attending clinicians, who may have attributed her serious symptoms to drug taking, thereby closing off in their minds to other avenues of inquiry.
Whilst the Coroner ultimately determined that there was no culture of inappropriate bias in connection with patients who have taken illicit drugs, it was nonetheless found that at least one of the clinicians who had attended Ms Hunter had attributed her symptoms to her drug use and in the absence of this information, might have otherwise considered sepsis.
This serves as a salient reminder to emergency clinicians to check their assumptions and potential biases when assessing patients who have taken drugs.
Pain management
Criticism was also made of the pain management available to Ms Hunter, who reported 10/10 pain on presentation to triage. Whilst there was much discussion about the impact that ambulance ramping and fragmentation of care had on the availability of stronger forms of analgesia for patients reporting acute pain, it was noted that the failure to provide Ms Hunter with adequate pain relief was both unsatisfactory and may have contributed to difficulties experienced by clinicians in taking reliable observations which, if properly obtained, would have likely signposted her deteriorating clinical status.
High index of clinical suspicion for sepsis
Although it was acknowledged that the sepsis cases that come before the coroner tend to involve unusual or atypical presentation, the inquest and the consequent recommendations emphasised the need for clinicians, including nurses who undertake triage assessments, to maintain a high index of clinical suspicion for sepsis in all patients reporting acute, non-specific symptoms.
Conclusion
Whilst the Coroner was not critical of the individual practitioners involved and it was agreed by experts that Ms Hunter’s prospect of survival were limited even before her presentation to hospital given the severe and invasive nature of her meningococcal disease, the finding that the care provided by the hospital was substandard has the potential to give rise to subsequent civil proceedings.
It was emphasised by lawyers for the hospital, that ED overcrowding and ambulance ramping are problems that are not confined to Western Australia, but are trends being noted both nationally and internationally. However, as illustrated by this matter, there are opportunities for individual clinicians to mitigate the risks posed by these resourcing challenges – not only as means of improving patient outcomes, but also as a protection against legal scrutiny.
A link to the Coroner’s findings is here.
