Inquest into the death of Maureen Smith

CORONERS COURT OF NEW SOUTH WALES

Inquest:

Inquest into the death of Maureen Anne Smith

Hearing dates:

26, 27 and 29 October 2021;

6 June 2022; and

13 to 15 September 2022

Date of findings:

21 August 2023. Corrigendum issued 25 August 2023.

Place of findings:

Coroners Court, Lidcombe

Findings of:

Magistrate Harriet Grahame, Deputy State Coroner

Catchwords:

CORONIAL LAW –

Glen Innes District Hospital,

Armidale Rural Referral Hospital, referral of medical

practitioner to

the Australian Health Practitioner

Regulation Agency Medical Council of NSW, signs of

clinical deterioration due to sepsis, septicaemia,

septic arthritis, Between the Flags, inter-hospital

transfer delays, systems for inter-hospital transfers in

regional areas, vital signs observations

File Number:

2018/103054

AMENDED PURSUANT TO THE IMPLIED POWERS TO CORRECT A JUDGMENT AS

SET OUT IN ACHURCH V THE QUEEN (2014) 253 CLR 141

Representation:

Ms K Edwards and Ms S Danne, Counsel assisting

the

Coroner instructed by Ms S Pickard, Department of

Communities and Justice

Mr B Bradley instructed by Ms L Blair, Crown Solicitor’s

Office, on behalf of Hunter New England Local Health

District, NSW Ambulance, HealthShare and NSW

Pathology

Mr N Dawson

instructed by Mr B Thompson, NSW

Nurses and Midwives Association, on behalf of Ms A

Cupitt, Ms J Murphy, Ms H Conyard, Mr R MacLean, Ms

D Cox, Ms J Sillitoe, Ms J Mulvey, Ms A Pietsch, Ms E

McLoughlin and Ms J Dijkstra

Ms L Toose, NSW Nurses and Midwives A

ssociation, on

behalf of Ms C Tierney

Mr R Coffey instructed by Mr A Deards, Makinson

d’Apice Lawyers, on behalf of Dr J Natukokona

Mr J Harris instructed by Ms E Marel, Avant Mutual, on

behalf of Dr M Manning

Dr P Dwyer instructed by Mr E Hui, Mills Oakle

y, on

behalf of Mr M Dunworth

Parties who did not appear at oral hearing

Ms A Lowe, unrepresented

Ms D Jackson, MDA National, on behalf of Dr R Diebold

Ms G Wright, KC Louise Jardim i

nstructed by Ms S

Dow, DLA Piper,

on behalf of Mr M Al-Amin

Findings

I make the following findings pursuant to s 81 of the

Coroners Act 2009 (NSW):

Identity

The person who died was Maureen Anne Smith

Date of death

She died on 1 April 2018

Place of death

She died at

Armidale Rural Referral Hospital, Armidale

NSW

Cause of death

She died of septicaemia (Staphylococcus aureus) with

the antecedent cause of septic arthritis.

Manner of death

There were systemic errors in the management of

Maureen’s condition which caused her transfer

between hospitals to be delayed overnight. This had

the cascading effect of delaying the commencement of

AMENDED PURSUANT TO THE IMPLIED POWERS TO CORRECT A JUDGMENT

REPRESENTATIVES

antibiotic treatment and resulted in Maureen receiving

sub-optimal care.

Recommendations

To the Australian Health Practitioner Regulation

Agency (AHPRA) Medical Council of NSW

1. That Dr Jauncy Natukokona (also known as Robert

Hakwa) be referred to the Australian Health

Practitioner Regulation Agency Medical Council of

NSW for investigation of his clinical conduct and

that a copy of these findings be forwarded

to assist with that investigation.

To Glen Innes District Hospital

An audit process of appropriate nursing records

should be undertaken at Glen Innes District

Hospital, including the use of Standard Audit

General Observation charts, fluid charts, recording

of hourly rounding and recording of observations,

with a view to improving these matters to attain an

acceptable standard if the result of that audit were

to demonstrate system issues. Such audit should

be conducted at least twice yearly, for a trial period

of two years and the capacity to be ongoing, in

order to identify trends.

To Hunter New England Local Health District, NSW

Ambulance and Patient Transport Services

3. That communications between transport agencies

in relation to a patient transfer should involve the

treating doctor whenever possible, but especially in

relation to any potential

change to the medically

agreed timeframe, to avoid incorrect information

concerning the diagnosis or urgency being passed

on second or third hand.

To Hunter New England Local Health District and

Patient Transport Services

4. That an inter-hospital

booking for specialist

treatment cannot be made with Patient Transport

Services (via any method, whether directly or via

Patient Flow Unit) unless a

medically agreed

timeframe has been agreed between the sending

AMENDED PURSUANT TO THE IMPLIED POWERS TO CORRECT A JUDGMENT

RECOMMENDATION 1

and receiving staff (by doctors unless unavailable)

and recorded in the Patient Transport Services

system.

5. That the Hunter New England Local Health District

urgently consider and address the following issues

as part of the pilot Medically Agreed Timeframe

Project:

provide a solution for obtaining a medically

agreed timeframe where the three-

way

phone call between the Patient F

low Unit,

the referring clinician and the accepting

clinician is bypassed;

provide certainty that a “force function” can

be implemented in the Patient Flow Portal

and the Patient Transport Service

Computer Aided Dispatch when the booking

does not come th

rough the Patient Flow

Portal;

c. provide a mechanism to enforce the Local

Health District

updating changes to the

medically agreed timeframe in the booking

system;

clarify the trigger for the proposed

escalation pathway for notifying the Local

Health Distri

ct when Patient Transport

Services does not have capacity to conduct

a transfer including whether it is an

automated or a human function;

clarify whether the proposed notification

system leaves time for the patient transfer

to be reallocated to another service in order

to meet the original medically agreed

timeframe; and

f. remove the time estimate pre-generated by

the Patient Transport Services booking

system as it risks confusing the medically

agreed timeframe.

To Hunter New England Local Health District

That Patient Flow Unit should record telephone

calls in order to further improve training and

performance, including to assist with accurate

audits of the number of patients transferred within

the relevant medically agreed timeframe.

To NSW Ambulance

That NSW Ambulance consider undertaking an

audit of outcomes from overflow transfer requests

including:

whether they were triaged through the

Virtual Clinical Coordination Centre;

whether NSW Ambulance undertook the

transfer within 24 hours or otherwise; and

c. whether (and the circumstances in which)

the transfer request was sent back to

Patient Transport Services.

Table of Contents

Introduction .......................................................................................................................... 7

The role of the coroner and the scope of the inquest ........................................................... 8

The evidence ....................................................................................................................... 8

Fact finding and chronology ............................................................................................... 10

Standard of care ................................................................................................................ 10

Factual findings in relation Dr Natukokona’s evidence ................................................... 11

The standard of care provided by Dr Natukokona .......................................................... 13

The standard of care provided by Dr Manning ............................................................... 15

The standard of nursing care ......................................................................................... 16

Transfer delay .................................................................................................................... 19

Failure to seek or obtain a medically agreed timeframe (MAT) ...................................... 19

The coordination role of PFU ......................................................................................... 21

The disproportionate weight on “between the flags” ....................................................... 21

Failures in the making and transfer of bookings ............................................................. 22

NSWA culture of preserving resources .......................................................................... 23

Determination of patient suitability and care provided by PTS ....................................... 24

The resourcing issues ........................................................................................................ 25

The need for recommendations ......................................................................................... 25

Findings ............................................................................................................................. 25

Identity ............................................................................................................................ 25

Date of death .................................................................................................................. 25

Place of death ................................................................................................................ 25

Cause of death ............................................................................................................... 25

Manner of death ............................................................................................................. 26

Conclusion ......................................................................................................................... 28

Introduction

1. This inquest concerns the tragic death of Maureen Anne Smith. Maureen was 75 years of

age when she died at Armidale Rural Referral Hospital (ARRH) on 1 April 2018 after a

delay

ed transfer from Glenn Innes District Hospital (GIDH) for specialist attention.

2. Maureen was described as a strong and independent woman. She had two sons, William

and Craig Wilson, with whom she maintained regular contact. She often looked after her

grandchildren when living close to them.

3. Maureen was a kind neighbour and formed a quick friendship with Leann Nixon when they

lived on the same street. Maureen and Leann remained close friends long after Maureen

moved away, with Leann visiting her nearly every day and assisting with Maureen’s care

when her health began to decline.

4. Up until she turned 50, Maureen was a fit and healthy woman who worked as a cleaner. In

March 1994, Maureen suffered a fall at work and underwent back surgery. The surgery

provided inadequate pain relief. Ongoing treatment included administration of Pethidine,

Valium and Stemetil.

5. In July 2008, Maureen sustained further injuries when a motorbike fell on her. In 2009, she

was referred to an orthopaedic surgeon for the treatment of her resulting hip ulcers and

ongoing management of pain in her right knee, right shoulder and left hip. In 2011, Maureen

was diagnosed with chronic methicillin-resistant staphylococcus aureus (MRSA) arising

from the ulcer in her left hip. Specialist consultations continued until her death.

6. In March 2018, Maureen received steroid injections into her hip, knee and shoulder. It was

around this time that William and Leann began to observe a decline in Maureen’s health.

7. On 31 March 2018, Maureen was admitted to GIDH by Ambulance suffering uncontrolled

pain. She was admitted under Dr Manning, a locum medical officer. A determination was

made between Dr Manning and the accepting Orthopaedic Registrar at ARRH, Dr

Natukokona, to transfer Maureen to

GIDH ARRH for a knee aspiration. The systematic

errors whic

h caused Maureen’s transfer to be delayed overnight had the cascading

effect of delaying the commencement of antibiotic treatment. Maureen passed away

shortly after her arrival at GIDH ARRH the following morning.

8. The transportation issues and subsequent decision-making of medical staff were important

issues explored in this inquest and a series of improvements have been identified as a

result.

AMENDED PURSUANT TO THE IMPLIED POWERS TO CORRECT A JUDGMENT

PARAGRAPH 7

The role of the coroner and the scope of the inquest

9. The role of the coroner is to make findings as to the identity of the nominated person and in

relation to the place and date of their death. The coroner is also to address issues

concerning the manner and cause of the person’s death.

A coroner may make

recommendations, arising from the evidence, in relation to matters that have the capacity

to improve public health and safety in the future.

The evidence

10. Unfortunately, these proceedings occurred some time after Maureen’s death, having been

delayed for a number of reasons including COVID-19 restrictions. There were times when

the passage of time affected the memory of a witness.

11. The court took evidence over 7 hearing days. The court also received extensive

documentary material in seven volumes, as well as audio visual material. This material

included witness statements, medical records and expert reports. The court heard oral

evidence from doctors and nurses involved in Maureen’s medical care and transport. The

court was also assisted by expert evidence from:

a. Professor William Rawlinson, Infectious Diseases Physician;

b. A/Professor Anna Holdgate, Senior Staff Specialist in Emergency Medicine;

c. Registered Nurse (RN) Eunice Gribbin, Expert Nursing Consultant; and

d. A/Professor Nigel Hope, Orthopaedic Registrar.

12. A/Professor Hope’s report was provided by representatives for Dr Natukokona during the

hearing and was tendered, after A/Professor Holdgate and RN Gribbin had concluded their

evidence and after Professor Rawlinson had been excused as no parties required his

attendance. He was not called to give oral evidence. I note there was no request from any

party to call him.

13. While I am unable to refer specifically to all the available material in detail in my reasons, it

has been comprehensively reviewed and assessed.

14. The following list of issues was prepared before the proceedings commenced:

a. Whether the care and treatment provided to Maureen by GIDH from 31 March 2018 to

1 April 2018 was adequate and appropriate (having regard to her medical history and

clinical condition), including:

Section 81 Coroners Act 2009 (NSW).

Section 82 Coroners Act 2009 (NSW).

a. the manner in which her presenting condition and the risk of developing

sepsis syndrome was identified;

b. the manner in which the sepsis pathway was implemented;

c. the application of the sepsis pathway to the circumstances of the regional

Local Health District (LHD) having regard to (amongst other matters):

i. potential delays in transport and/or obtaining pathology results; and

ii. the decision to withhold antibiotics for a patient with possible sepsis or

septic joint pending transfer to ARRH for a joint aspiration;

d. the decision to withhold antibiotics when it became clear that Maureen would

not be transported to ARRH on 31 March 2018;

e. the frequency of monitoring and observation of Maureen, particularly

overnight; and

f. the medical and nursing staff response to Maureen’s deteriorating condition,

particularly her increasing confusion/delirium.

b. Whether the advice provided by the Orthopaedic Registrar at ARRH was appropriate,

particularly with respect to the provision of antibiotics, throughout the period of

Maureen’s treatment at GIDH and ARRH having regard to her medical history and

clinical condition.

c. The circumstances in which Maureen’s transfer to ARRH was delayed, including

whether:

a. Maureen was appropriately triaged as a non-urgent patient;

b. urgent transport (by ambulance) should have been provided to ARRH on 31

March 2018 or 1 April 2018;

c. medical and nursing staff at GIDH should have responded differently when

transport was refused or delayed (both in terms of her treatment and further

attempts to ensure there was urgent transportation); and

d. the applicable policies, procedures and guidelines were appropriate?

d. The adequacy of pathology arrangements operative during after hours, on weekends

and during public holidays in the Hunter New England (HNE) LHD, including in an

emergency situation.

e. Whether any recommendations are necessary or desirable in connection with

Maureen’s death, including the advice provided to locum doctors at GIDH.

15. These issues guided the investigation. However, the inquest process tends to crystalize the

issues in real contention and I intend to address those issues under several broad headings.

Fact finding and chronology

16. Prior to commencing the inquest, those assisting me prepared a summary of facts taken

from the extensive available material. The document was circulated to the parties a

agr

eement was reached in relation to the summary of facts contained. That document is

annexed at Appendix A. It accurately sets out a chronology of events and for that reason I

do not intend to repeat all those details here. It should be read in conjunction with these

reasons.

17. Among other things it records the time, place and medical cause of Maureen’s death. Thes

atters, on which I must make findings pursuant to section 81 of the Coroners Act, were

not in dispute. Maureen died at ARRH on 1 April 2018. I accept the forensic pathologist’s

opinion, which was supported by each of the independent experts, that her medical caus

of death

is appropriately recorded as septicaemia (Staphylococcus aureus) wi

th the

antec

edent cause of septic arthritis. Further, I accept the opinions of both Professor

Rawlinson and A/Professor Holdgate that it is most likely the joint injections whic

h had

occurred in March 2018 were the source of the septic arthritis which later became

gener

alised sepsis. Given that these matters were essentially uncontested, the heari

foc

ussed broadly on the manner of Maureen’s death, which in turn included examinati

on of

her

treatment and transfer between hospitals.

18. Further evidence was received in oral testimony relating to Maureen’s medical care and the

decisions made in relation to her transfer. There was also evidence relati

ng to the

ocedures and processes now in place with respect to hospital transfers and expected

levels of care. Counsel assisting have also summarised much of this material in thei

omprehensive closing submissions. I rely heavily on their submissions to set out further

chronological details and aspects of the expert evidence in these reasons, where

appr

opriate incorporating their words. I have also had the opportunity to consult

comprehensive submissions from the each of the parties and I have adopted their

submissions where appropriate.

19. Counsel assisting identified a number of key issues and it is efficient to deal with each in

tur

Standard of care

20. The inquest shed light on shortcomings in the standard of care provided to Maureen,

including failures to identify cognitive deterioration and other “soft” signs of septicaemia

(referred to from this point onwards as sepsis); the inappropriateness of a decision to

withhold antibiotics in respect of suspected sepsis when it was clear that Maureen would

not be transferred on 31 March 2018; the lack of appropriate and timely observations; and

failures to escalate transportation issues.

21. Despite the shortcomings, no expert identified a singular deficiency by any medical

practitioner or agency that directly caused Maureen’s death. Rather, as stated by

A/Professor Holdgate, ‘there were cumulative deficiencies which could have played a

causative role’. Accordingly, I accept the submission of Counsel assisting that Maureen’s

death was not definitively avoidable. However, I also accept that her prospects of survival

were diminished by the fact that she ultimately did not receive appropriate care. To this end,

the inquest heard evidence on the standard of care provided by Dr Michael Manning (the

referring clinician), Dr Jauncy Natukokona (the accepting specialist) and nursing staff, each

of which is addressed below.

Factual findings in relation Dr Natukokona’s evidence

22. Before considering the standard of care provided by the clinicians, it is necessary to resolve

factual conflicts which arose from Dr Natukokona’s evidence. At the time of Maureen’s

death, Dr Natukokona had been practicing as an Orthopaedic Registrar in Australia for 15

years and was the on-call orthopaedic specialist at ARRH.

23. Counsel assisting identified examples where Dr Natukokona contradicted his own evidence,

the evidence of other staff, documentary evidence and expert opinions. Relevantly, where

inconsistencies were put to Dr Natukokona, he was unwilling to make concessions on

untenable positions or to concede the possibility that his recollection had been impacted by

the passage of time.

24. On this basis, Counsel assisting submitted that Dr Natukokona was a poor witness whose

evidence should be treated with caution and that it should be accepted that Dr Natukokona:

a. had been told by Dr Michael Manning, during their first telephone conversation, that

Maureen had a swollen and warm right knee, a cystic outpouring in her shoulder and

had also been advised of point of care blood test results that Dr Manning had available

to him at that time, including the white cell count and lactate results;

b. had, at least by the time of his second call with Dr Manning, the point of care blood test

results available to him on the Clinical Applications Portal system (CAPS), excluding

the C-reactive protein results;

c. did not seek to clarify Dr Manning’s ability to perform a knee aspiration at GIDH (which

Dr Natukokona conceded);

d. did not participate in a three-way telephone call between Dr Manning and the Patient

ow Unit (PFU) and only spoke to Dr Manning twice on 31 March 2018;

e. did not access CAPS a third time on 31 Marc

h 2018;

f. advised Dr Manning during both calls to withhold antibiotics; and

g. adv

ised Dr Manning to administer paracetamol in the event Maureen developed a fever

overnight.

25. Counsel for Dr Natukokona responded that he had been unfairly criticised by Counsel

assisting and the court should make no finding that he was untruthful. In summary, it was

submitted that no regard was given to the concerns raised or the subsequent observations

of the court; that English is not Dr Natukokona’s first language; that he was unfamiliar wi

the c

ourt environment and giving evidence; and that his evidence was substantially impeded

by use of the audio-visual link (AVL).

26. In their submissions in reply, Counsel assisting responded that there was no applicati

ade for an interpreter and that counsel for Dr Natukokona had been expressly invited to

alert the court of any concerns about Dr Natukokona’s understanding of what was bei

asked. A presumption was also made in relation to the level of English language proficiency

that is required to practice as an Orthopaedic Registrar in Australia, as Dr Natukokon

a had

been doi

ng for 15 years.

27. In respect of unfamiliarity with court and giving evidence, Counsel assisting stated that few

witnesses are familiar with the circumstances of giving evidence in court and that questions

were repeated where there were difficulties with AVL. It was also raised that Dr Natukok

ona

as legally represented by counsel who could and did object at times where the evidence

was impeded by AVL, and that Dr Natukokona was given multiple opportunities to address

critical matters.

28. Counsel assisting reiterated that Dr Natukokona’s unwillingness to concede that his

memory may have lapsed due to the passage of time was an issue, noting for completeness

that he was not deprived of the opportunity to prepare, review evidence or seek legal advice.

29. Having reviewed the evidence I accept Counsel assisting’s submission that Dr

Natukokona’s evidence should be treated with caution. Where his recollection of event

onflicted with the recollection of Dr Manning, I prefer Dr Manning’s account. I do not acc

ept

that l

anguage difficulties might explain certain discrepancies in the accounts he gave.

num

ber of his explanations were inherently implausible.

The standard of care provided by Dr Natukokona

30. Counsel assisting submitted that Dr Natukokona made the following unsafe decisions in

aureen’s care and incorrect observations about her condition:

a. the direction to withhold antibiotics in the second telephone call with Dr Manning after

it was clear Maureen would not be transferred that day;

b. the direction to Dr Manning to administer paracetamol in the event Maureen developed

a fever overnight (despite agreeing this would be dangerous advice, Dr Natukokona

denied giving it);

c. maintaining during his evidence that there was no swelling or obvious drainable joint

effusion when he examined Maureen’s knee, despite evidence to the contrary from

Enrolled Nurse Cupitt, Dr Manning, Dr Holdgate, the pathologist and photographs i

ich the swelling was clear to a layperson; and

d. confusion of the suprapatellar and prepatellar bursa during his evidence, a matter

which raised concerns from A/Professor Holdgate about his understanding of the skills

required to act as an Orthopaedic Registrar.

31. In circumstances where patient care had resulted in a sub-optimal outcome, Counsel

assisting raised concern about Dr Natukokona’s apparent lack of honesty and his

unwillingness to accept circumstances which could cause reviewers real difficulties i

under

standing clinical issues. It was submitted that this may not have impacted Maureen’s

care but caused ongoing concern in relation to his care of other patients and potentially his

engagement with supervising clinicians and bodies.

32. Counsel assisting also posited that if Dr Natukokona’s evidence was to be accepted (and

contrary to Counsel assisting submissions), that his lack of clinical curiosity about impor

tant

agnostic information raised serious concerns about his conduct including his failure

fol

low up results where he stated that Dr Manning had told him that he was unsure of the

results or that they were unavailable and failing to discuss with Dr Manning the possibility

of a Maureen undergoing a knee aspiration at GIDH.

33. It was recommended that Dr Natukokona be referred to the Australian Health Practitioner

Regulation Agency (AHPRA) for investigation into his unsafe practices.

34. Counsel for Dr Natukokona responded that a referral to AHPRA would be unnecessary

ubmitting that an orthopaedic expert should have, or should now be called;

that

/Professor Hope’s expert report should be wholly accepted; that A/Professor Holdgate’s

evidence should not be accepted without qualification; and that there was no explanati

why Dr Natukokona’s supervisor, Dr Diebold, was not called to give evidence.

35. Counsel for the HNELHD, NSW Ambulance (NSWA), HealthShare and NSW Pathology

(the Health Agencies) also stated that it was regrettable that evidence was not called from

an orthopaedic specialist. It was added that criticisms of clinicians ought to be tempered by

the challenges under which they operated on the day.

36. In reply, Counsel assisting clarified that A/Professor Hope’s report could be accepted to the

extent that it was consistent with the evidence of A/Professor Holdgate and Professor

Rawlinson. It was identified that A/Professor Hope had been served with an incomplete set

of medical records and was asked to make assumptions that were not capable of being

established from the evidence at inquest. As a result, A/Professor Hope’s report failed to

address the critical issue of the advice to withhold antibiotics on the evening of 31 March

2018 based on the information provided by Dr Manning. Yet Dr Natukokona, A/Professor

Hope, A/Professor Holdgate and Professor Rawlinson each accepted that it would have

been inappropriate to give such advice.

37. I was also persuaded that A/Professor Holdgate’s many decades of experience working

with orthopaedic registrars gave her a sound basis to offer an opinion on this issue.

38. It should be remembered that I accept Dr Manning’s evidence in relation to the

conversations he had with Dr Natukokona and am satisfied that Dr Natukokona advised Dr

Manning to withhold antibiotics during the second telephone call. A/Professor Hope’s written

report did not grapple with this evidence and there was no request for him to be called to

provide an oral opinion.

39. Counsel assisting submitted that the only issue relevant to an orthopaedic specialist was

whether Dr Natukokona should have followed up more proactively in relation to Maureen’s

transfer and care. This issue was dealt with in the report of A/Professor Hope and by

Counsel assisting, without raising criticism of Dr Natukokona beyond his own concessions.

By contrast, A/Professor Hope was not asked to comment on the evidence concerning the

photographs of Maureen’s knees in respect of his ability to identify an effusion. Nor did he

identify any point of disagreement when he was expressly provided with an opportunity to

identify aspects of the other experts’ reports with which he disagreed.

40. I have considered the issue of referral carefully and am satisfied that a referral to the

AHPRA Medical Council of NSW should be made in relation to Dr Natukokona. Leaving

aside the evidence of A/Professor Holdgate and Professor Rawlinson about Dr

Natukokona’s ability to give appropriate orthopaedic care on the evening, I remain

concerned about the doctor’s honesty and capacity to engage with this inquiry with

openness and insight.

AMENDED PURSUANT TO THE IMPLIED POWERS TO CORRECT A J

UDGMENT

PARAGRAPH 40

The standard of care provided by Dr Manning

41. At the time of Maureen’s admission, Dr Manning was a locum doctor attending GIDH for the

first time over an Easter long weekend. He was a very junior doctor who was provided with

limited assistance and relied upon the specialist advice he sought from the on-call

orthopaedic registrar at ARRH. Dr Manning made an apology in court that demonstrated he

had reflected deeply and had learnt from the events of Maureen’s death. He also engaged

with the HNELHD to improve the GIDH orientation guide in response to Maureen’s death.

The updates have now been implemented across all sites in the Tablelands sector.

42. I observed Dr Manning as he gave his evidence and he impressed the court as a thoughtful

and compassionate doctor who did his best to assist the court with honesty and with insight.

I had considerable sympathy for the position he found himself in on the evening he cared

for Maureen. He was relatively inexperienced and had never worked at GIDH before. He

was the only doctor at GIDH over the weekend and he had very limited training in the local

systems.

43. Counsel for Dr Manning submitted, consistently with Counsel assisting, that there would be

no criticism of Dr Manning beyond noting the following reasonable concessions:

a. Dr Manning did not appreciate the significance of the point of care blood test lactate

results on 31 March 2018, being unfamiliar with the machine and noting the sign which

stated ‘WBC & Diff estimate only’;

b. his handwritten progress notes should have been timestamped;

c. that, in retrospect, Maureen’s raised heart rate in the afternoon of 31 March 2018 was

clinically significant – though he had expected Maureen’s observations would show a

clear deterioration;

d. that he was the clinician responsible for Maureen;

e. that his primary diagnosis was for a condition beyond his scope of practice and that,

when seeking advice, Dr Natukokona was relying on his clinical assessments and

observations;

f. that he had a greater responsibility for transfer and should have done more to advocate

for Maureen’s transfer, including speaking directly to NSWA – though he understood

from RN Raymond MacLean that further deterioration would need to occur before

NSWA would consider transfer that day;

g. he may have been able to escalate his concerns about withholding antibiotics to a more

senior staff member – though he was the only doctor on shift and did not know who to

contact;

h. that he should have overridden the advice to withhold antibiotics – though he did not

have the confidence to do so at the time and without a change to Maureen’s

observations;

i. that he expected Maureen would be kept under regular observation on the war

d but

should have specifically documented and advised nursing staff to conduct close

observations overnight, at least four-hourly;

j. that he did not appreciate that increasing confusion or delirium indicated a clinical

emergency when observations were otherwise “between the flags;”

k. that he did not think to contact Dr Natukokona about the clinical changes on

the

orning of 1 April 2018;

l. that he was facing other demands but should have checked on Maureen again in

the

morning of 1 April 2018, to ensure her transfer had occurred; and

m. he s

hould have reviewed Maureen and taken observations when prescribing Morphine

on 1 April 2018 – although he was busy in the emergency department at the time and

was prioritising Maureen;s transfer.

44. I accept A/Professor Holdgate’s opinion that Dr Manning correctly identified the relevant

clinical issues during his first consultation with Maureen. He then correctly and promptly

discussed her ongoing care with the orthopaedic on-call registrar at ARRH, who apparently

agreed she should be transferred. Tragically a number of factors beyond Dr Manning’s

direct control delayed that transfer and Maureen’s care was severely compromised.

45. It is very clear that Dr Manning has learnt from the events leading up to Maureen’s death.

In my view he has carefully considered what occurred and I offer no particular criticism of

him, beyond the concessions he properly made.

The standard of nursing care

46. Statements were obtained from eleven nurses who provided care to Maureen during her

admissions at GIDH and ARRH. Oral evidence was given by RN MacLean and by expert

nur

sing consultant RN Gribbin, who had provided two reports in the matter. At

the

onclusion of the evidence, three issues remained with the standard of nursing car

ovided to Maureen

47. Before dealing with the issues below, it is relevant to firstly consider the submission made

by Counsel for ten of the nurses (the nurses)

, that “no weight can be given to RN Gribbin’s

opinion.” During her evidence, it came to light that aspects of RN Gribbin’s CV were

RN Amy Cupitt, EN Jeanette Murphy, RN Heather Conyard, RN Raymond MacLean, RN Dimity Cox, RN

Joanne Sillitoe, RN Joanne Mulvey, RN Adriana Pietsch, RN Ebony McLoughlin and RN Jodie Dijkstra

incorrect and/or misleading. Evidence was led that she had relied upon outdated Standards

and Codes of Professional/Ethical Conduct in her reports, claimed to be an expert on

competencies and incorrectly applied Standards for Registered Nurses to Enrolled Nurses

when separate Standards were in existence. While these concerns are clearly valid and

somewhat concerning, I do not accept that no weight should be given to RN Gribbin’s

evidence. A/Professor Holdgate made similar conclusions.

48. The first issue related to the frequency of monitoring and observations. Between 8.45pm on

31 March 2018 and Maureen’s transfer to ARRH at 2pm on 1 April 2018, only one set of

observations were recorded, at 6.45am on 1 April 2018. Although RN Conyard stated that

hourly rounds were performed on the patients overnight, including Maureen, no records and

no fluid balance charts were kept. Dr Manning gave evidence that he instructed the nursing

staff to contact him immediately upon any signs of deterioration overnight and, upon

discovery that no observations had taken place on the morning of 1 April 2018, was advised

by nursing staff there would be follow up. No effective follow up occurred.

49. I accept A/Professor Holdgate’s evidence that no reliable conclusion can be drawn about

what Maureen’s observations would have revealed about her condition and whether earlier

identification of her decline would have resulted in life-saving care. Nevertheless, I remain

troubled by the omission.

50. Counsel assisting submitted that it be recommended that a twice-annual audit process of

appropriate nursing records should be undertaken at GIDH, including the use of Standard

Audit General Observation (SAGO) charts, the use of fluid charts, recording of hourly

rounding and recording of observations; with a view to improving these matters to attain an

acceptable standard if the result of that audit were to demonstrate system issues.

51. Counsel for the nurses supported the recommendation and proposed that it be expanded

to include nursing staffing, nursing skill mix and medical coverage on nights, weekends and

public holidays.

52. Counsel for the Health Agencies did not support the recommendation due to existing annual

audits of SAGO charts/observations, ad hoc audits of fluid charts and GIDH’s 97%

compliance rate with a HNELHD Sepsis Audit performed in 2020. It was submitted that the

diversion of resources was not necessary or desirable to improve public health and safety.

53. I disagree. I remain concerned about what was disclosed in the medical records in this case.

An audit may assist in identifying whether the problem is ongoing. I intend to make the

recommendation suggested by Counsel assisting and supported by the nurses in this

matter.

54. The second issue related to the appropriate diagnosis and treatment of sepsis. In her

evidence, A/Professor Holdgate identified “soft” signs of sepsis which may have been

detectable on 1 April 2018. These included an increased level of confusion and a drop in

oxygen levels. Maureen’s confusion was recorded by nursing staff at 6pm on 31 March

2018, at 7am on 1 April 2018 and she was described as “off with the fairies” at 7.28am on

1 April 2018. I accept the retrospective evidence of Dr Manning and the opinion of

A/Professor Holdgate that doctors and nursing staff are jointly responsible for recognising

the signs of sepsis and that the description of Maureen as “off with the fairies” indicated a

clinical emergency.

55. The court heard evidence that HNELHD have taken steps to increase awareness of the

signs of sepsis by providing a “Sepsis Kills” training course and to include sepsis education

in the monthly mandatory training day for clinical staff. The Health Agencies also jointly

proposed more frequent sepsis audits and further sepsis training. Counsel for the nurses

welcomed the proposed training.

56. I am heartened by the approach to this important issue. Clearly Maureen’s declining

cognitive function should have been a red flag.

57. The third issue was that Maureen’s transfer to ARRH should have been escalated.

Specifically, in the afternoon of 31 March 2018, when it appeared that a same day transfer

would not occur. Then again in the morning of 1 April 2018, when transport was delayed.

58. At the first opportunity for escalation, RN MacLean did not strongly advocate for Maureen’s

transfer. RN MacLean assisted the court by providing a detailed account of the challenges

he had faced on at least two prior occasions when advocating for patient transport. I accept

his evidence on this issue. His experiences included NSWA not accepting his views on risk

of deterioration, NSWA not accepting risk of deterioration as a reason for ambulance

transfer and NSWA not accepting patients who were “between the flags.” RN MacLean

appropriately conceded that he should not have provided a working diagnosis of

“Osteomyelitis” when booking Maureen’s transfer and that he may have been mistaken

about his recollection of making a second call to NSWA.

59. At the second opportunity for escalation, nursing staff failed to notify Dr Manning of the

delay and no action was taken to escalate her care despite her decline. Counsel assisting

submitted that A/Professor Holdgate’s evidence that these failures represented serious

departures from an acceptable standard of care and were missed opportunities should be

accepted. I accept this submission. However, I do not propose to make any criticisms of

individual nursing staff in light of the resourcing issues and broader transfer

recommendations set out below.

Transfer delay

60. The inquest heard evidence that the first attempt to arrange Maureen’s transfer occurred at

1.22pm on 31 March 2021, when nursing staff called the Patient Flow Unit (PFU) requesting

a same-day transfer for a “R septic knee joint.” No booking was made at the time and, due

to a subsequent series of system failures and human errors, Maureen’s transfer did not

commence until 2pm on 1 April 2018.

61. A conclave of institutional representatives from HNELHD, NSWA, PFU and Patient

Transport Services (PTS)

gave evidence addressing some of the matters. I agree with the

submission of Counsel assisting that the conclave evidence indicated a strong level of

collaboration between the transport agencies and reduced the number of recommendations

that may have otherwise been necessary or appropriate. I was heartened by the obvious

desire of all parties to improve the relevant systems and do better in the future. However,

in my view, the following issues remained outstanding following the conclave evidence and

further documents produced in respect of pilot programs which were first referred to during

their evidence.

Failure to seek or obtain a medically agreed timeframe (MAT)

62. The HNELHD and NSWA Inter-hospital Patient Transport Process dated December 2017,

stated that the time to dispatch should be a MAT between the referring clinician (RN or

medical officer) and the accepting medical officer. Three bookings were made for Maureen’s

transfer. The first, on 31 March 2018 at 2.17pm with PTS. Then at 3.13pm, when the

booking was transferred to NSWA and finally, on 1 April 2018 at 7.28am, when the transfer

was rebooked with PTS. A/Professor Holdgate concluded that there had been a breach of

policy, as there was clearly no MAT given in any of the bookings when Dr Manning and Dr

Natukokona wanted Maureen to be transferred on 31 March 2018, not the following day.

63. The conclave gave evidence that following Maureen’s death the MAT issues have been

addressed by the PTS no longer taking bookings with an urgency of less than 2 hours and

with the introduction of a pilot program known as the “MAT Project.” While the MAT Project

represents a positive step towards addressing the issues, Counsel assisting identified

several possible gaps in the MAT Project including:

a. there is no solution to obtaining a MAT where the three-way phone call between PFU,

the referring and the accepting doctors is bypassed;

b. there is no certainty that the proposed “force function” stopping staff from entering a

booking without a MAT will be implemented, given the evidence of PFU that no such

PTS was known as Non-Emergency Patient Transport in 2018. Both organisations were part of HealthShare.

function currently exists, or whether a similar function would be used by the PTS

Computer Aided Dispatch when the booking does not come through the Patient Flow

Portal;

c. there is no enforceability mechanism to ensure that the LHD updates changes to the

MAT in the system or to ensure that both doctors are consulted on the update;

d. a lack of clarity around the proposed trigger notifying a LHD where PTS does not have

capacity to complete a booking, including whether it will allow time for transfer to

another transport agency; and

e. there is no evidence that the PTS pre-generated time estimate based upon a service

level agreement with the LHDs has been removed from the booking system.

64. Counsel assisting proposed three recommendations in respect of the MAT issues. First,

that an inter-hospital booking for specialist treatment cannot be made with PTS via any

method unless a MAT has been agreed between the sending and receiving physicians and

recorded in the PTS system. Second, that the HNELHD urgently consider and address the

issues raised in paragraph [63] as part of the pilot MAT Project. Third, that communications

between the relevant transport agencies in relation to a patient transfer should involve the

treating doctor whenever possible, but especially in relation to any change to the MAT, to

avoid incorrect information concerning the diagnosis or urgency being passed on second

or third hand.

65. Counsel for the Health Agencies did not support the recommendations. In respect of the

first recommendation, it was submitted that there are circumstances, including at nurse led

facilities, where patient transfer must be arranged with nursing staff at the sending facility

or without a medical officer available. I accept the submission that the recommendation, as

drafted, does not reflect the reality of nurse led facilities. Nevertheless, in my view, subject

to a small amendment, it is an appropriate recommendation which arises from the evidence

in this inquest.

66. It was submitted that second recommendation was unnecessary and will not improve public

safety in circumstances where the pilot program is funded and designed to look at the

subject matters. As I have stated I am heartened by the cooperative work that has gone into

the pilot MAT project. Nevertheless, a recommendation provides some transparency in

relation to the issues that may be considered. I accept the pilot program is likely to continue

its work and I intend to recommend that issues directly arising from this inquest are

specifically considered.

67. It was submitted that the third recommendation did not arise from Maureen’s death, as no

evidence had been led which suggested that nursing staff changed the MAT. Counsel for

the Health Agencies also submitted that such a recommendation would be unnecessary

and treating doctors ought not to be involved “wherever possible” in the escalation pathway.

In my view the recommendation is pertinent to the facts in this case. The importance of

setting a MAT, with a clinician if possible, in order to avoid second or third hand information

impacting transport critical decisions was revealed in the evidence in this inquest. I intend

to make the recommendation for further consideration by the relevant agencies.

The coordination role of PFU

68. During Maureen’s admission there were three telephone calls with PFU, none of which were

recorded or resulted in a transportation booking. The inquest heard evidence that the role

of PFU has subsequently changed, so that all inter-hospital transfers booked between 7am

and 9pm should commence with a three-way conference call, providing for limited

exceptions.

69. During the conclave evidence, Counsel assisting put forward the option for PFU to take on

a bigger role in the patient transfer system. The conclave responded that this would be an

unsuitable option due to resourcing issues, the exceptionally large geographical area of

HNELHD and in circumstances where previous efforts to prevent bookings outside the

system have been unsuccessful.

70. Counsel assisting also proposed that PFU should implement a telephone recording system,

in-line with NSWA and PTS. The conclave raised resourcing issues as a barrier to

implementation.

71. Counsel assisting submitted that the accountability and rigour of recording calls outweighed

the resourcing limitations raised by the HNELHD witness and recommended that PFU

should record telephone calls in order to further improve training and performance, including

to assist with accurate audits of the number of patients transferred within the relevant MAT.

72. Counsel for the Health Agencies did not support the recommendation. It was submitted that

HNELHD had considered and rejected recording calls on the basis that the PFU phone

system is incompatible with recording devices, where HNELHD does not have capacity to

store such information and, considering the cost and impracticalities, recording is unlikely

to provide a public benefit.

73. In my view, further consideration should be given to this issue. Aside from resourcing

constraints, no cogent reason was supplied to reject a recommendation which is likely to

improve service delivery.

The disproportionate weight on “between the flags”

74. At the time of Maureen’s admission, both NSWA and PTS had “between the flags” as clinical

criteria in their booking policies and/or systems. Noting A/Professor Holdgate’s evidence on

the “soft” signs of sepsis, there appeared to have been a disproportionate focus placed on

whether Maureen was “between the flags” when booking and re-booking her transfer. In

particular at 5.07pm on 31 March 2018, when NSWA deemed Maureen’s case unsuitable

for ambulance transfer despite being advised that the referring and receiving clinicians

wanted her transferred that day.

75. The HNELHD and NSW Inter-hospital Patient Transport Process (as at 31 March 2018 and

the updated version of 2019) already require transport agencies to consider whether a

patient is likely to deteriorate and whether they fall “between the flags.” The process does

not permit selective priority between the two. In light of the MAT recommendations

described above, and given that physicians are likely to be more confident and competent

providing a MAT as a predictor for deterioration, it appears that no further recommendations

are required in relation to this issue.

Failures in the making and transfer of bookings

76. The inquest heard examples of occasions where incorrect information was conveyed from

the medical staff at GIDH to the transport services in relation to Maureen’s condition.

Namely, that she had been diagnosed with osteomyelitis and that she did not have “MRO’s

of infections”. At all relevant times, Dr Manning had advised staff that the transfer was for

“investigations of a possible septic joint.” In other words, an infection but not one of

contagion for the purposes of the safety of transport staff.

77. The provision of incorrect information, in turn, raised problems during the transfer of the

initial PTS booking to the NSWA Electronic Booking System (EBS), as the incorrect

diagnosis was passed on whereas the accurate note of “R septic knee joint” was omitted.

Similarly, the lack of a MAT and the failure to contact either hospital to advise the medical

staff of the booking change, meant NSWA received no indication of the urgency of the

transfer.

78. Since Maureen’s death, the “Ways of Working” pilot program has been established between

HNELHD and HealthShare. Where PTS cannot facilitate a booking, Ways of Working now

requires PTS to contact the ward that made the booking and request a rescheduled time or

to advise them to rebook through NSWA. I am satisfied that the Ways of Working program

has alleviated some of the risks that misinformation will be passed between transport

agencies and ensures the Hospital is notified when a transfer requires

rescheduling/rebooking.

79. Counsel assisting identified a series of additional missed opportunities. These included the

failure of NSWA call-taker, Mark Dunworth, to ask any follow-up questions about Maureen’s

condition during the call with PTS to transfer the booking at 4.49pm on 31 March 2018; Mr

Dunworth’s failure to interact with a treating doctor or accept that doctor’s assessment of

urgency; Dr Manning’s failure to speak with NSWA directly when he became aware of the

refusal to transfer; and an overarching failure to determine the real urgency of Maureen’s

clinical condition. Each matter was conceded by the individual and/or agency to which it

related.

80. In March 2020, the HNELHD issued an updated Clinical Policy Compliance Procedure

“Inter-Facility Transfer for Patients requiring Specialist Care”, which stated that the referring

medical officer is to “[d]etermine the transport modality and level of clinical escort required

in consultation with the receiving Specialist.” I accept the submission of Counsel assisting

that this policy, if complied with, operates to avoid practitioners being presented with similar

inter-hospital transfer issues today.

NSWA culture of preserving resources

81. NSWA is mandated to provide an “overflow” service where PTS does not have the

resources to conduct a transfer. Counsel assisting submitted that even in circumstances

where NSWA considered the booking to be non-urgent, their initial reluctance to conduct

Maureen’s transfer, despite having ambulances available, demonstrated that the overflow

service was ineffective.

82. During the conclave evidence, Mr Robert Fairey, Associate Director of Clinical Operations

at the NSWA Western Control Centre, accepted that resource preservation was a cultural

issue, whereby staff did not want to conduct non-urgent transfers and leave themselves

unable to respond to more acute patients. However, Mr Fairey gave evidence that since

2018, new staff and improved education on MATs are contributing to a shift away from the

resource preservation culture.

83. Separately, Mr Fairey gave evidence of a new Virtual Clinical Coordination Centre (VCCC)

which was expedited to respond to COVID-19 surges. While still in the preliminary process

of implementation, the VCCC’s primary functions are to provide a secondary triage of low

acuity incidents to reduce avoidable transfers by NSWA, improve ambulance availability for

high acuity patients and provide linkages to community services.

84. Counsel assisting welcomed the VCCC and proposed a recommendation that NSWA

consider undertaking an audit of outcomes from overflow transfer requests including

whether they are triaged through the VCCC, whether NSWA undertook the transfer within

24 hours or otherwise, or whether (and the circumstances in which) the transfer request

was sent back to PTS.

85. Counsel for the Health Agencies did not support the recommendation. It was submitted that

auditing results of overflow patient transfers during a pandemic and before the complete

design and implementation of the VCCC would be of limited utility and an inefficient use of

resources. It was further submitted that the parameters relating to transfers undertaken in

less than 24 hours, and referrals back to PTS, either did not arise in the context of

Maureen’s death and/or are irrelevant to improving patient outcomes.

86. In my view the longstanding cultural issue of “resource preservation” was starkly in evidence

in this case. Mr Robert Fairey described the phenomenon, but it was also indicated in the

evidence given by RN Maclean when he was questioned about the possibility of escalating

Maureen’s transportation. His clear evidence of challenges and indeed “push back” when

requesting assistance of NSWA was suggestive of the way (well motivated) resource

guarding may affect patient care. In my view an audit is an appropriate way to assess the

continued relevance of this factor. I intend to make the recommendation.

Determination of patient suitability and care provided by PTS

87. At the time of Maureen’s death, PTS operated on the premise that patients were only

booked with their service if they were within the service scope. The reason being that PTS

staff were not trained to determine the suitability of patients for PTS transport. This may

have led to some of the missed opportunities described above.

88. In March 2020, PTS introduced a new position of Clinical Assessment & Triage (CAT) nurse

to assist with clinical triage, review of bookings and to deal with escalations and clinical

questions. Since Maureen’s death, PTS policy has also changed to require all patients with

a MAT of under 2 hours to be booked with NSWA and the Ways of Working program has

introduced daily meetings between the transport agencies to discuss transfer needs. I

commend these changes and accept they are an improvement to public safety and reduce

the risk of patients, such as Maureen, regrettably falling through the gaps.

89. In respect of the care provided by PTS, the medical records raised some concerns with

Maureen’s management. In particular, upon her arrival at ARRH, Maureen was left without

medical or nursing staff for just over 10 minutes while handover occurred in a nearby triage

room. Maureen went into cardiac arrest shortly after handover. I accept A/Professor

Holdgate’s opinion that it would have been more appropriate for handover to occur in

Maureen’s presence to improve chances of earlier recognition of her significant

deterioration and consequently, earlier commencement of resuscitation. I also accept her

opinion that the events following Maureen’s arrival at ARRH had no impact on the manner

or cause of Maureen’s death.

The resourcing issues

90. I acknowledge that resourcing issues were a theme in the evidence concerning the

challenges at GIDH, ARRH and in connection with transferring patients throughout the

HNELHD. I accept that resourcing issues informed Maureen’s care in multiple ways which

were not limited to vehicle allocation, doctor availabilities and nursing coverage. However,

these issues can and have been considered by specialist bodies, such as the “NSW

Parliamentary Inquiry into health outcomes and access to health and hospital services in

rural, regional and remote New South Wales”. I do not propose to consider the matters

beyond noting their consistency with some of the evidence heard in this inquest.

The need for recommendations

91. Section 82 of the Coroners Act 2009 (NSW) confers on a coroner the power to make

recommendations that he or she may consider necessary or desirable in relation to any

matter connected with the death with which the inquest is concerned. It is essential that a

coroner keeps in mind the limited nature of the evidence that is presented and focuses on

the specific lessons that may be learnt from the circumstances of each death.

Findings

92. The findings I make under section 81(1) of the Coroners Act 2009 (NSW) are:

Identity

The person who died was Maureen Anne Smith

Date of death

She died on 1 April 2018

Place of death

She died at Armidale Rural Referral Hospital, Armidale NSW

Cause of death

She died of septicaemia (Staphylococcus aureus) with the antecedent cause of septic

arthritis.

Manner of death

There were systemic errors in the management of Maureen’s condition which caused her

transfer between hospitals to be delayed overnight. This had the cascading effect of

delaying the commencement of antibiotic treatment and resulted in Maureen receiving sub-

optimal care.

Recommendations pursuant to section 82 Coroners Act 2009

93. For the reasons stated above, I recommend:

To the Australian Health Practitioner Regulation Agency (AHPRA) Medical Council of

NSW

1. That That Dr Jauncy Natukokona (also known as Robert Hakwa) be referred to the

Australian Health Practitioner Regulation Agency Medical Council of NSW for

investigation of his clinical conduct and that a copy of these findings be

forwarded to assist with that investigation.

To Glen Innes District Hospital

2. An audit process of appropriate nursing records should be undertaken at Glen

Innes District Hospital, including the use of Standard Audit General Observati

harts, fluid charts, recording of hourly rounding and recording of observations,

with a view to improving these matters to attain an acceptable standard if the resul

of that audi

t were to demonstrate system issues. Such audit should be conduc

ted

at least twice yearly, for a trial period of two years and the capacity to be ongoing,

in order to identify trends.

To Hunter New England Local Health District, NSW Ambulance and Patient

Transport Services

3. That communications between transport agencies in relation to a patient transfer

should involve the treating doctor whenever possible, but especially in relation to

any potential change to the medically agreed timeframe, to avoid incorrect

information concerning the diagnosis or urgency being passed on second or third

hand.

o Hunter New England Local Health District and Patient Transport Services

4. That an inter-hospital booking for specialist treatment cannot be made with Patient

ansport Services (via any method, whether directly or via Patient Flow Unit)

unless a medically agreed timeframe has been agreed between the sending and

receiving staff (by doctors unless unavailable) and recorded in the Pati

ent

AMENDED PURSUANT TO THE IMPLIED POWERS TO CORRECT A JUDGMENT

RECOMMENDATION 1

Transport Services system.

5. That the Hunter New England Local Health District urgently consider and address

the following issues as part of the pilot Medically Agreed Timeframe Project:

a. provide

a solution for obtaining a medically agreed timeframe where the

three-way phone call between the Patient Flow Unit, the referring clinician

and the accepting clinician is bypassed;

b. provide certainty that a “force function” can be implemented in the Patient

Flow Portal and the Patient Transport Services Computer Aided Dispatch

when the booking does not come through the Patient Flow Portal;

c. provide a mechanism to enforce the Local Health District updating changes

to the medically agreed timeframe in the booking system;

d. clarify the trigger for the proposed escalation pathway for notifying the Local

Health District when Patient Transport Services does not have capacity to

conduct a transfer including whether it is an automated or a human function;

e. clarify whether the proposed notification system leaves time for the patient

transfer to be reallocated to another service in order to meet the original

medically agreed timeframe; and

f. remove the time estimate pre-generated by the Patient Transport Services

booking system as it risks confusing the medically agreed timeframe.

To Hunter New England Local Health District

6. That Patient Flow Unit should record telephone calls in order to further improve

training and performance, including to assist with accurate audits of the number of

patients transferred within the relevant medically agreed timeframe.

To NSW Ambulance

7. That NSW Ambulance consider undertaking an audit of outcomes from overflow

transfer requests including:

a. whether they were triaged through the Virtual Clinical Coordination Centre;

b. whether NSW Ambulance undertook the transfer within 24 hours or

otherwise; and

c. whether (and the circumstances in which) the transfer request was sent

back to Patient Transport Services.

Conclusion

94. I offer my sincere thanks to the assisting team, Kirsten Edwards, Sarah Danne, and Sian

Pickard for their hard work and enormous commitment in the preparation of this matter

and in drafting these findings.

95. Finally, once again I offer my sincere condolences to Maureen’s family, especially her

sons, Craig and William, and to her friend Leann.

96. I close this inquest.

Magistrate Harriet Grahame

Deputy State Coroner, NSW State Coroner’s Court, Lidcombe

21 August 2023

A. BACKGROUND ............................................................................................................................ 2

B. PRIOR MEDICAL ISSUES ........................................................................................................... 2

Historic medical issues ........................................................................................................... 2

Medical issues present in 2018 ............................................................................................... 4

C. 31 MARCH 2018: ADMISSION TO GIDH .................................................................................. 5

Ambulance to GIDH and initial patient assessments ............................................................. 5

First review by Dr Michael Manning at GIDH ...................................................................... 6

First contact with orthopaedic registrar at ARRH ................................................................ 11

Further care and attempts to arrange transfer to ARRH ....................................................... 13

Ms Smith’s care after it was clear there would be no transport on 31 March 2018 ............. 29

Second review by Dr Manning ............................................................................................. 30

Second contact with orthopaedic registrar at ARRH ............................................................ 32

D. 1 APRIL 2018: GIDH CARE ....................................................................................................... 34

E. 1 APRIL 2018: PTS ARRIVAL AT GIDH AND TRANSFER TO ARRH ................................. 40

F. 1 APRIL 2018: ARRIVAL AT ARRH, HANDOVER AND TREATMENT .............................. 44

Arrival at ARRH ................................................................................................................... 44

Handover / Triage – timing and location .............................................................................. 44

Handover / Triage – notes .................................................................................................... 47

Transfer of Ms Smith to resuscitation bay ............................................................................ 48

Resuscitation attempt ............................................................................................................ 49

Dr Natukokona’s involvement in Ms Smith’s treatment at ARRH ...................................... 49

Subsequent events that day ................................................................................................... 50

G. POST MORTEM RESULTS AND EXPERT ANALYSIS .......................................................... 50

APPENDIX A

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

___________________________________________________________________________

Summary of evidence

as at 12 September 2022

__________________________________________________________________________

Contents

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

A. BACKGROUND

1. Ms Maureen Anne Smith (previously known as Maureen Pettit) was born on 19

December 1942 and died on 1 April 2018 at Armidale Rural Referral Hospital (ARRH)

aged 75 years. Ms Smith and her husband had divorced, and she had two sons, Mr Craig

Wilson and Mr William Wilson aged approximately 51 and 56 respectively. Both sons

were in contact with Ms Smith in the lead up to her death.

2. The autopsy report by Dr Hannah Elstub dated 3 October 2018, with reference to the

autopsy undertaken on 6 April 2018 (Autopsy Report), concludes the direct cause of

Ms Smith’s death was “Septicaemia (Staphylococcus Aureus)” with antecedent cause of

“Septic Arthritis of right knee” and other significant conditions contributing to the death

being emphysema and osteoarthritis.

According to Professor William Rawlinson, the

most likely cause of death was septicaemia, following the spread of a methicillin-sensitive

staphylococcus aureus (MSSA), which is an organism that is sensitive to certain

antibiotics such as flucloxacillin.

3. Septicaemia is the presence of disease-causing bacteria in the blood. According to the

Sepsis Toolkit, produced by the Clinical Excellence Commission,

sepsis is regarded as a

medical emergency, being:

A life-threatening condition that arises when the body’s response to infection injures its

own tissues and organs… Delayed treatment is associated with high mortality rates

4. Further, the Sepsis Toolkit explains that:

Sepsis is a difficult clinical diagnosis that requires experience and a high index of suspicion

for interpretation of history, signs and symptoms. Early senior clinician involvement is

imperative to ensure that the required skills and knowledge are available to facilitate

appropriate diagnosis and management.

B. PRIOR MEDICAL ISSUES

Historic medical issues

5. Ms Smith had a complicated medical history spanning at least 15 years

including long-

standing back pain, osteoarthritis, previous left femoral fracture with surgical fixation,

Tab 2 Autopsy Report, p.2

Tab 23 Expert Report of Professor Rawlinson, p.3 at [3.0] and p.4 at [4.0(4)]

Tab 26 Sepsis Toolkit, p.7

Ibid, p.18

Tab 4 Statement of Craig Wilson, at [4]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

pressure ulcers, peripheral vascular disease, gastro-oesophageal reflux and iron deficiency

anaemia.

6. In March 1994, Ms Smith suffered a fall at work and subsequently had a lumbar

laminectomy and a spinal fusion, which did not provide adequate relief from back pain.

Treatment continued for many years including administration of Pethidine, Valium and

Stemetil.

7. On 31 July 2008, Ms Smith was admitted to ARRH as a result of injuries sustained when

a motorbike fell on her.

8. On 5 November 2009, Dr Ee Kong Wong, Ms Smith’s general practitioner, referred her

to Dr Robin Diebold, Orthopaedic Surgeon, regarding pressure sores at both hips and

various subcutaneous infections in both upper thighs following left inguinal abscess

drained in Armidale in 2008 after the motorbike incident.

9. During the period 2009 to 2018, Ms Smith had numerous consultations with Dr Diebold,

during which time Dr Diebold arranged ongoing management for Ms Smith’s hip ulcers

and treatment for ongoing pain in her right knee, right shoulder and left hip. Dr Diebold

notes that at examination of Ms Smith on 24 January 2018, the wounds and ulcers had

healed.

The last such consultation was on 21 March 2018.

10. On 10 January 2011, samples were taken from a swab of a wound on the left hip, showing

“occasional” methicillin-resistant staphylococcus aureus (MRSA).

According to

Professor Rawlinson, MRSA is a community strain which is resistant to certain

antibiotics.

On 8 January 2015, further samples were taken and the resulting pathology

showed “scanty” MRSA arising from a “L hip chronic ulcer” microbiology culture,

and

a culture taken 17 March 2014 showed “profuse” MRSA.

Tab 2 Autopsy Report, p.2

Tab 19A Letter from Dr Lewis to Dr Wong, p.122

Tab 19A Letter to Dr Chowdhury, p.123

Tab 19A, ARRH Discharge Referral Notes from 2008, pp.23-26

Tab 19A, Letter from Dr Wong to Dr Diebold, p.49 and Response from Dr Diebold, p.51

Tab 8 Statement of Dr Diebold, at [45]

Ibid

Tab 19A Microbiology Report dated 13 January 2011, p.17

Tab 23 Expert Report of Professor Rawlinson, p.4 at [4.0(4)]

Tab 19A Microbiology Report dated 12 January 2015, p.5 and 23 April 2014, p.9

Ibid

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

11. On 6 July 2016, Glen Innes District Hospital (GIDH) medical records confirm that Ms

Smith was monitored for sepsis

and then transferred to ARRH on 7 July 2016 for

further management of pneumonia. ARRH records Ms Smith was admitted until 21 July

2016 for hospital acquired pneumonia and that Ms Smith suffered chronic MRSA arising

from an ulcer in her left hip.

12. A/Professor Anna Holdgate opines that the history of previous staphylococcus aureus

infection did not have any major bearing on Ms Smith’s treatment in 2018.

She states

that while Ms Smith’s history of chronic ulcers and positive MRSA swabs increased her

risk of developing septic arthritis, she had both of conditions for many years without

developing sepsis.

13. Professor Rawlinson observes that the previous MRSA was not the causative organism

involved in the sepsis presentation at the time of Ms Smith’s death, although it is possible

that Ms Smith had MRSA infection coexistent with the causative MSSA organism.

Medical issues present in 2018

14. In or around December 2017, Ms Smith had a fall for which she was still seeking

treatment in early 2018.

15. On 27 February 2018, Ms Smith was reviewed by Dr Wong for “Pain. 4 weeks ago was

wheeling out wheelie bin fell on RT knee … Tenderness medial patella WT bearing

Likely sub periosteal haematoma”. Dr Wong ordered X-ray right knee and prescribed

Ordine.

16. On 12 March 2018, Ms Smith attended at ARRH and had steroid injections into the hip

and knee, performed by Dr Victor Petroff, specialist radiologist, upon referral by Dr

Diebold. Dr Petroff used imaging guidance (CT guidance for the hip, ultrasound

guidance for the knee) and an aseptic technique.

17. A/Professor Holdgate confirms that intra-articular steroid injections carry a small risk of

secondary septic arthritis which cannot be fully eliminated, even in the most expert

Tab 19A Adult Sepsis Pathway, Sepsis Management Plan from 2016, pp.128-131

Tab 19A ARRH ED Triage Notes from 2016, p.124

Tab 24A Expert Report of A/Professor Holdgate, at [2.1]

Ibid, at [2.1]

Tab 23 Expert Report of Professor Rawlinson, p.3 at [4.0(2)] and p.4 at [4.0(4)]

Tab 19A Letter from Dr Diebold to Dr Phillip Brownlie dated 24 January 2018, p.4

Tab 19A Clinical Notes dated 27 February 2018, p.84

Tab 19A INT Consultation with Patient Report, Armidale Radiology, p.3

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

hands. An aseptic technique is appropriate, requiring cleaning the skin and use of sterile

equipment and medications.

18. On 21 March 2018, Dr Diebold reviewed Ms Smith and noted that the recent injections

of 12 March had provided her with partial relief of her symptoms, and he administered

a steroid injection into Ms Smith’s right subacromial bursa, in her right shoulder.

Diebold’s notes state that he has “not arranged to see her again at this stage”.

19. Ms Leanne Nixon, a long-time friend of Ms Smith’s observed that in “[t]he days after

the shots Maureen kept complaining of soreness and general unrest” and on or around

30 March 2018, Ms Nixon observed large blister on Ms Smith’s right shoulder (the

injection site for the cortisone), which “looked like a burn blister it was risen and

appeared to be full of fluid”.

20. One of Ms Smith’s sons, Mr William Wilson, went to stay with her ‘around February to

March 2018 and states that her health was on a rapid decline while he was there.

states:

I would often find her asleep at the kitchen table or on the floor asleep. She would walk

around the kitchen talking to herself, I would say she was starting to become almost

delirious. … she was barely eating…

C. 31 MARCH 2018: ADMISSION TO GIDH

Ambulance to GIDH and initial patient assessments

21. At 9.58am, an ambulance was called to attend Ms Smith.

22. Mr William Wilson, states that he made that telephone call.

The ambulance records

show “Caller Name” as “LEE NIXON”.

23. At 10.11am, an ambulance was dispatched, and Ms Smith was taken to GIDH.

24. The ambulance reports states:

Tab 24A Expert Report of A/Professor Holdgate, at [7.3]

Tab 8 Statement of Dr Diebold, at [47]

Tab 19A Dr Diebold Patient Notes dated 21 March 2018, p.1; Letter from Dr Diebold to Dr Brownlie dated 21

March 2018, p.2

Tab 5 Statement of Leanne Nixon, at [7] and [10]

Tab 6 Statement of William Wilson, at [8]

Ibid

Tab 21 NSWA Records

Tab 6 Statement of William Wilson, at [9]

Tab 21 NSWA Records, Incident Detail Report, p.1

Tab 21 NSWA Records

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

O/A pt 75yo female, c/o pain and weakness in bilateral arms and legs. Pt has chronic

pain, usually controlled with own meds and cortisone injections

Pt had cortisone injections 2/7 ago and has had uncontrolled pain since.

Pt has raised, tight red lumps at injection sites.

Not hot to touch.

O/E pt alert and oriented, c/o pain.

25. There are conflicting reports of Ms Smith’s precise time of arrival at GIDH but it was

some time after 11:00am.

GIDH Emergency Department (ED) Triage notes show that

Ms Smith was assigned triage category 4: Semi-Urgent,

noting that Ms Smith:

presents with Pain – Generalised, Pt BIBA i/c chronic pain Received cortisone injection

in doctors rooms last week Right shoulder red and inflamed but not hot.

26. The nurse in charge at GIDH at the time (from 7.00am until 2.30pm) was Registered

Nurse (RN), Dimity Cox.

27. Enrolled nurse (EN) Amy Cupitt states that at the time of admission, Ms Smith ‘was

alert and orientated’ and on presentation to the emergency department, was complaining

of severe pain in her right knee. EN Cupitt confirmed in her statement that “[O]n

inspection her knee was swollen, warm and tender to touch”.

28. According to Professor Rawlinson, Ms Smith did not present with generalised sepsis

initially, noting the following:

blood pressure was 120/73 mmHg …

respiratory rate 20bpm consistent with a person of her age with her smoking history …

heart rate of 95bpm – elevated, although again consistent with a woman with her condition

…

no fever, no urinary symptoms, and initially no altered cognition.

First review by Dr Michael Manning at GIDH

29. Dr Michael Manning was a locum medical officer at GIDH, completing a locum

placement over the Easter long weekend at the time.

30. In his statement, Dr Manning says that:

Tab 21 NSWA Records, p.2

Tab 21 NSWA Records indicate, the ambulance was “@ destination” at 11.26am, “Triage” was recorded at

11:28am and “Off Stretcher” occurred at 11:32am; Tab 19A GP Patient Notification from HNELHD to Dr

Wong dated 31 August 2018, p.92 indicated an admission date and time of 31 March 2018 at 11.35am citing

“Problem / Procedure: fall”

Tab 19 GIDH Records

Tab 18C Statement of Lisa Ramsland, at [59]

Tab 10 Statement of EN Cupitt, at [6]-[7]

Tab 23 Expert Report of Professor Rawlinson, p.3 at [4.0(1)]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

Shortly after Ms Smith’s presentation to ED, once I had finished reviewing the other

patient in ED, I attended and reviewed Ms Smith. Ms Smith had been triaged and

transferred to an ED bed.

31. Upon examination, Dr Manning noted the following in relation to Ms Smith, without

recording a time of review:

75♀ Multifocal Pain

called ambulance for lower

back pain and pain in

all limbs

- denies fevers

- no n [?nausea] or v [?vomiting]

R knee and lower lumbar

back are foci of pain

Increasing each day,

on 5mg of oral ordine [?morphine] BD [?twice daily]

but now no longer

controlling pain.

10/7 interarticular cortisone

– pain worsening since then

B/D [?] chronic pain

nicotine dependence

PVD [?peripheral vascular disease]

Meds

Amitriptyline 20mg

Morphine 5mg BD

O/E 120/73 RR [?respiratory rate] 20 H95 [?heart rate 95]

Cachetic

C/O [?Complaining of] pain in lumbar back and knee

Chest – reduced a/e [air entry] no creps [?crepitations]

HSD [?Heart sounds dual]

Abdo [?Abdomen] soft no mass

R Knee

warm and swollen

Active movement 30 degrees

Tender to palpation but not severe

Feet perfused.

Pulses weak,

consistent with PVD [?peripheral vascular disease].

R shoulder

– non-tender large ganglion

Imp [?Impression] Possible developing septic R knee

missed courier for bloods / CRP

AKI [?Acute kidney injury]

Tab 7 Statement of Dr Manning, at [29]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

S/W Ortho @ Armidale

- requests no abs

- review in ED Armidale

- fresh bloods

S/W ED and advised of transfer

Plan: For t/f to Armidale for

ortho review

Bloods

Blood culture

IV fluids

- [chase] previous bloods for renal #

analgesia

given going for ortho review will not aspirate here.

32. In his statement, Dr Manning recalled that:

Ms Smith’s right shoulder appeared to have a cystic outpouching from the joint capsule.

This seemed to rise out from the joint and appeared quite prominent. It had the clinical

appearance of a ganglion or out-pouching from the joint capsule of the shoulder. It was

not warm or tender upon palpation and Ms Smith appeared to have reasonable

movement and function of her right shoulder.

33. According to Dr Manning, he had been informed that GIDH did not have any x-ray

services available that day.

34. Dr Manning states that he undertook Point of Care (blood) Testing (PoCT) on Ms

Smith.

35. At 11.55am, PoCT device was processed by Operator ID 51005884, which identified

neutrophils were 21x10

/L and the white blood cell count was 26.6x10

/L.

36. Professor Roger Wilson, Chief Pathologist and Executive Director Clinical Governance

and Quality at NSW Health Pathology confirms in his statement that the monitoring of

quality control testing and performance of the PoCT device located at GIDH was up to

date for the expected testing intervals with results of those tests within the expected

range, indicating reliable performance.

Professor Wilson also states that PoCT is

reliable and replicate testing by a referral laboratory to confirm PoCT results should be

avoided, except in the case of critical or spurious results.

He states that there were

Tab 19 GIDH Records

Tab 7 Statement of Dr Manning, at [46]

Ibid, at [55]

Ibid, at [51]

Tab 19 GIDH Records [Note: Tab 19A contains a clearer copy of the PoCT test print]

Tab 15 Statement of Professor Roger Wilson, at [7]

Ibid, at [9]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

protocols in place at GIDH for transporting pathology specimens by taxi for ‘extreme

emergencies’.

37. A handwritten note was recorded as being taken at 12.10pm, at the bottom of a form

titled ‘Emergency Department Triage Notes’:

Nursing: PT BIBA GENERALISED PAIN AND A RED INFLAMED R

SHOULDER. HAD A CORTISONE INJ LAST WEEK IN DR’S ROOMS.

SHOULDER SITE NOW RED AND [?] BUT NOT HOT. BLOODS (I-STAT)

PTO

(CONT) AND FORMAL, BLOOD CULTURES ATTENDED. IV FLUIDS

COMMENCED AND PAIN RELIEF GIVEN. [RML] RN MacLean.

38. At 12.10pm PoCT device CG4+ test was processed by Operator ID 51005884, which

identified lactate 2.29mmol/L.

39. At 12.14pm PoCT device CHEM8+ test was processed by Operator ID 51005884,

which identified creatinine 196 mmol/L and urea 26.1 mmol/L.

40. Results of bedside blood tests were attached to Dr Manning’s notes, demonstrating,

according to A/Professor Holdgate:

a. “markedly” elevated urea and creatinine;

b. a “markedly” elevated white cell count, (which A/Professor Holdgate notes was

not commented upon); and

c. a “mildly elevated” lactate level of 2.29mmol/L.

41. According to A/Professor Holdgate:

a. initial lactate levels of >2mmol/L along with worsening confusion are both in the

“yellow zone” criteria of the NSW Health adult sepsis pathway (Sepsis

Pathway);

b. no “red zone” criteria of the sepsis pathway were identified; and

Tab 15 Statement of Professor Roger Wilson, at [11]

Tab 19 GIDH Records, commences pp.46-47

Ibid

Ibid; Expert Report of A/Professor Holdgate, at [1.9] as to subparagraph (c), Tab 24C Second Supplementary

Report of A/Professor Holdgate, p.3

Tab 26 Sepsis Toolkit, p.17 describes “Sepsis Pathways”

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

c. Ms Smith also had two recognised risk factors for sepsis, being the presence of the

chronic wound on her left hip and her age, being over 65.

42. While acknowledging certain limitations of the Sepsis Pathway, A/Professor Holdgate

opines that Ms Smith demonstrated sufficient clinical signs to raise suspicion for sepsis

at this stage.

43. Professor Rawlinson states that Ms Smith had risk factors for sepsis but did not, using

the Sepsis Pathway, have significant risk factors

including that she “did not demonstrate

any red zone observations”

and did not have significant yellow zone observations under

the Sepsis Pathway.

Professor Rawlinson observes that to be a “yellow zone

observation”, systolic blood pressure must be less than 100 mmHg and to be a “red zone

observation”, systolic blood pressure must be less than 90 mmHg; Ms Smith’s was 120

mmHg.

44. Neither A/Professor Holdgate nor Professor Rawlinson state that treatment pursuant to

the Sepsis Pathway should have commenced at this point.

45. However, both those experts confirm that only a short delay is appropriate before

administration of antibiotics in these circumstances, such delay being acceptable for the

purpose of taking blood and other cultures.

46. In this case, cultures were required to be taken from Ms Smith’s knee joint, by an

aspiration procedure. Dr Manning states that he had not aspirated a knee joint on his

own prior to that time (although he had done so under supervision) and did not consider

attempting that procedure in the circumstances.

47. The Sepsis Toolkit does not recommend administration of antibiotics until recognition

or diagnosis of sepsis, but states that commencement of antibiotic therapy should occur

within the first hour of that recognition or diagnosis.

Tab 24A Expert Report of A/Professor Holdgate, p.8 at [4.1]

Ibid, at [4.3]

Tab 23 Expert Report of Professor Rawlinson, p.3 at [4.0(1)]

Ibid, p.4 at [4.0(3)]

Ibid

Ibid, p.3 at [4.0(2)]; Tab 24A Expert Report of A/Professor Holdgate, p.6 at [3.1]

Tab 7 Statement of Dr Manning, at [78]

Tab 26 Sepsis Toolkit, pp.17-18; Tab 18 Statement of Peter Williams, Annexure D Sepsis Data Collection Tool

Adult Inpatient (contemporaneous document)

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

48. A/Professor Holdgate states that diagnosis of a suspected septic joint is an orthopaedic

emergency which requires orthopaedic intervention that was not available at GIDH.

First contact with orthopaedic registrar at ARRH

49. At an unspecified time after his first review,

Dr Manning’s notes confirm that he had a

discussion with the Orthopaedic Registrar at ARRH, now known to be Dr Jauncy Robert

Hakwa Natukokona, with notes as follows:

Spoke with Orthopaedic Registrar at Armidale

- requests no antibiotics

-review in Emergency Department Armidale

-fresh bloods.

50. During their conversation, Dr Natukokona requested that Dr Manning not administer

antibiotics. This is confirmed by both Dr Manning and Dr Natukokona.

51. These conversations will be the subject of oral evidence.

52. Dr Manning’s notes further document that he then spoke with ED, noting:

Spoke with ED and advised of transfer

Plan: For transfer to Armidale for orthopaedic review

Bloods

Blood Culture

IV fluids

-chase previous bloods for renal #

analgesia

given going for orthopaedic review will not aspirate here.

53. In his statement Dr Manning confirms that he spoke with the on-call ED consultant at

Armidale Hospital on the FACEM phone to advise of Ms Smith’s impending transfer

and her presentation generally. Dr Manning stated that he relayed the instructions from

Dr Natukokona, including the x-ray to Ms Smith’s right knee and new blood tests upon

her arrival at ARRH ED, and that the consultant accepted the transfer and advised they

would await Ms Smith’s transfer.

54. Dr Ronald Hawksford has provided a statement confirming that he was working in the

ED at ARRH on 31 March 2018 between 7.30am and 5.30pm. Dr Hawksford further

confirmed that a copy of a Clinical Handover, Advice and Transfer of Care Form for

Tab 24A Expert Report of A/Professor Holdgate, at [2.4]

Tab 7 Statement of Dr Manning, at [54]

Tab 19 GIDH Records (extracted at paragraph [31] above, containing the full extract of related notes)

Ibid; Tab 9 Statement of Dr Natukokona, at [22(n)]; Tab 7 Statement of Dr Manning, at [57]

Tab 19 GIDH Records (extracted at paragraph [31] above, containing the full extract of related notes)

Tab 7 Statement of Dr Manning, at [59]-[60]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

Maureen Smith from ARRH is in his writing, and that the form would have followed a

telephone conversation from a doctor at GIDH regarding the transfer of Ms Smith. The

form noted as ‘Situation/Background’:

Ortho

↑ swilling of ® knee

post steroid injection

55. He further noted under ‘Recommendation/Request’ that Ms Smith was ‘Accepted by

Ortho’

56. Professor Rawlinson opines that where there is a likelihood of sepsis, particularly if a

diagnosis of septic arthritis is made, it is inappropriate for no antibiotics to be given for

an extended period. Where there is a provisional diagnosis of “sepsis syndrome” he

opines that urgent antibiotic treatment is indicated. Professor Rawlinson notes that in

this case, the provisional diagnosis was for localised sepsis i.e., not sepsis syndrome.

However, in the circumstances of Ms Smith’s age (>65 years), previous surgery to the

knee and recent hydrocortisone injection, it was not appropriate to withhold antibiotics

for any significant period of time.

57. At 1.05pm to 1.06pm, Dr Natukokona accessed the Clinical Applications Portal (CAP)

in relation to Ms Smith.

He states that CAP is a computer system which allows access

to certain patient records (for example, previous x-rays and blood test results) within the

Hunter New England Local Area Health District (HNELHD).

In his statement, Dr

Natukokona referred to accessing CAP after his first discussion with Dr Manning, and

again referred to accessing CAP at some time before 2pm.

58. The CAP search results show that the following searches were undertaken using Dr

Natukokona’s user identification, and were the only searches concerning Ms Smith or

the GIDH Emergency Department undertaken on CAP that afternoon:

a. “consolidated patient schedule, ED Search” (an ED Search), commencing at 1:05:11 pm

and ending at 1:05:11 pm;

Tab 17 Statement of Dr Hawksford, at [5]-[6]

Tab 23 Expert Report of Professor Rawlinson, p.5 at [4.0(5)]

Tab 22 Letter for Crown Solicitor’s Office, Annexure 1 CAP Audit Report

Tab 9 Statement of Dr Natukokona, at [23]

Ibid, at [22]-[26] and [32]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

b. immediately after, a patient search report relating to Ms Smith commencing at 1.05.19 pm

to and ending at 1.06.38 pm;

c. about twenty one minutes later, an ED Search commencing at 1:26:37 pm and ending at

1:26:37 pm; and

d. immediately after, an ED Search commencing at 1:26:49 pm and ending at 1:26:49 pm.

Further care and attempts to arrange transfer to ARRH

59. At 1.10pm, blood samples were taken.

60. Dr Manning states that he asked the ED Nurse in Charge how patients were transferred

to ARRH and he was advised that the nursing staff would book an ambulance for transfer

(Dr Manning said he understood the non-urgent patient transfer service was not

operating that day). Dr Manning states he advised the nurse that the transfer was for

“investigation of a possible septic joint”.

61. The Patient Flow Unit (PFU) notes show a PFU Request by “Michael” (also recording

“Doctor: Michael Manning”) at 1.22pm.

In her statement, Nurse Manager Lisa Welfare

at the PFU says “it appears” that at 1.22pm, she received a telephone call from Dr

Manning in relation to an inter-hospital transfer to ARRH for “R septic knee joint”,

although Ms Welfare also states that she has no independent recollection of her

involvement.

Dr Manning states that, to his recollection, he never made a phone call

to Ms Welfare.

62. At 1.26pm, PFU notes entitled “Transfer Request for Smith Maureen” (the Transfer

Request Record) include a record of the following, as well as noting Ms Welfare as

“PFU First Contact”:

(Lisa Welfare) R septic knee joint.

Dr Manning has spoken to Robert Hakwa and also ED – t/port has been booked

63. Ms Welfare says in her statement that the notes in the Transfer Request Record relating

to the 1.26pm call also state in the Transport section “Dr Manning – RN att” and that

Tab 22DDD Letter from the Crown Solicitor’s Office regarding CAP dated 29 October 2021; Tab 22J Letter

from the Crown Solicitor’s Office regarding CAP dated 16 March 2022 and 22M Letter from the Crown

Solicitor’s Office regarding CAP dated 12 May 2022

Tab 19A Pathology Report, p.132

Tab 7 Statement of Dr Manning, at [62]

Tab 22 Letter from Crown Solicitor’s Officer, Annexure 2a PFU Records

Tab 22A Statement of Ms Lisa Welfare, at [5] and [6]

Tab 7A Supplementary Statement of Dr Manning, at [37]

Tab 22 Letter from Crown Solicitor’s Officer, Annexure 2a PFU Records, p.2

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

the “Transport Arranged” section is ticked and explains her understanding of this is that

Dr Manning had informed her that a RN had attended to booking transport and further,

that she would not have been involved in the planning or timeframe of the transport.

64. At 1.32pm, the Transfer Request Record includes a record of the following:

(Lisa Welfare) R septic knee joint.

Dr Manning has spoken to Robert Hakwa and also ED – t/port has been booked.

Not through PFU

65. On the first page of the Transfer Request Record, the timeframe selected against that

transfer is “<24 hrs”. The other options for timeframe are “<1 hr”, “<12 hrs” and “>24

hrs”.

66. Ms Lisa Ramsland, A/General Manager, Tablelands Sector, HNELHD, states that the

selection of a timeframe ought to have been based on the medically agreed timeframe

(MAT) communicated by the referring and accepting doctors at the time of referral.

67. Ms Welfare says in her statement that, in accordance with her usual practice, this note

would reflect that she telephoned the ED of ARRH to confirm they were aware of the

booking.

68. In relation to the contact made with PFU, Ms Ramsland makes both of the following

statements:

a. “it is my understanding that PFU were not asked to coordinate the booking”;

and

b. “The PFU were not asked to co-ordinate this transfer”.

69. At 1.40pm, Morphine and paracetamol were administered and, according to the RN

Raymond MacLean, intravenous fluids were also commenced at this time.

70. At 2.05pm, nursing records note an entry by RN Dimity Cox that blood samples were

taken for formal pathology including blood cultures from “R) CF.”

71. At 2:17pm, RN MacLean made a phone booking (reference 1481416) with Non-

Emergency Patient Transport, HealthShare NSW. Non-Emergency Patient Transport is

Tab 22A Statement of Lisa Welfare, at [7]-[8]

Tab 22 Letter from Crown Solicitor’s Officer, Annexure 2a PFU Records, p.2; Tab 13A Statement of RN

MacLean, at [15]

Tab 18C Statement of Lisa Ramsland, at [46]

Tab 22A Statement of Lisa Welfare, at [10]

Tab 18C Statement of Lisa Ramsland, at [39]

Ibid, at [42]

Tab 19 GIDH Records

Ibid

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

now called Patient Transport Service (PTS) and remains part of HealthShare NSW. It

will be referred to as PTS throughout this Summary, although some of the

contemporaneous notes refer to “Non-Emergency Patient Transport”. The PTS

booking form records the following information, among other things:

a. Patient Info – R septic knee joint

b. Transfer Comment –

“DX: Osteomyelitis

HX: Chronic Pain

Accepted by Ortho Registrar for Ward via ED”

c. “Is the Patient Between the Flags? / Yes”

d. Pickup Time 31/03 14:10-16:20

e. Delivery Time 31/03 15:50-19:00

f. Status – “Cancelled”.

72. Dr Manning states that he has reviewed the PTS booking form and that he had not been

aware of the reference to “Osteomyelitis”. He also states that osteomyelitis would have

“been similar to my working diagnosis (septic arthritis) in terms of its implications and

urgency”.

73. PTS has confirmed that Ms Smith was classed as a ‘Class C transport” under the “Service

Specifications for Transport Providers, Patient Transport Service” published 12 January

2018.

The summary of a ‘Class C’ transport includes:

a. patient is expected to remain within ‘Between the Flags’ criteria;

b. may require equipment monitoring (with the exception of cardiac);

c. observation and monitoring of an intravenous infusion;

d. behaviourally stable;

e. condition is not life threatening and is not likely to become life threatening during

transport; and

Tab 18A, Annexure B

Tab 7A Supplementary Statement of Dr Manning, at [23]

Tab 22B Statement of Shubjeet Kaur, at [4]-[5]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

f. patients have been assessed by a registered nurse or medical practitioner as having

low risk of deterioration.

74. PTS has advised that an automated message is audible when HNELHD makes a booking

with PTS via telephone, which includes the following statement:

All patients must be assessed by an appropriately qualified nurse or medical practitioner

as suitable for patient transport service before making the booking.

75. Any PTS call taker is required to complete a digital “Call Taking Form” by asking certain

questions in relation to each transfer type.

76. PTS telephone transcripts show a call from RN MacLean to PTS, in which RN MacLean

spoke to “Stuart”, now known to be Stuart Reeves a Booking Officer at Greater

Metropolitan Booking Hub (GMBH), to organise the transfer of Ms Smith.

Some of

the conversation is noted below (with ellipsis representing minor comments or

interjections). After some introductory remarks, Mr Reeves confirmed his understanding

of the booking as:

… so what’ve we got, so is specialist care over to Armidale, hospital emergency … Who’s

the authorising doctor at Glen Innes

77. RN MacLean stated:

The authorising doctor is Dr Manning

78. After some administrative matters, the conversation continued as follows:

Mr Reeves: … and why did she present to Glen Innes Hospital?

RN MacLean: Um, she presented with osteomyelitis by the looks of it

Mr Reeves: osteomyelitis … Any other medical history with her?

RN MacLean: Um, just um chronic pain

Mr Reeves: chronic pain. Ok so transferring over to ED for investigations

RN MacLean: No, she’ll actually go in through ED, but she’s been accepted by the

orthopaedic reg down there, don’t ask me his name, my doctor didn’t

give it to me mate

Mr Reeves: That’s fine. So, accepted by ortho registrar. So going for a ward via ED

RN MacLean: via ED, yes mate

Mr Reeves: ok that’s fine mate, no problem at all. That patient’s going today, and

what time will that patient be ready?

Ibid, at [6]

Ibid, at [9] [Note: includes a transcript of the full automated message]

Ibid, at [10] and Annexures 3 and 4

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, Annexure H, p.1

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

RN MacLean: be ready from now

Mr Reeves: sorry from now?

RN MacLean: yep

Mr Reeves: ok sweet

RN MacLean: and if you’re really quick, I’ve got two ambo’s sitting here doing nothing

[laughter]

79. In some further exchanges, RN MacLean confirmed that Ms Smith is “between the flags”

and responds “no” when Mr Reeves asks if she has any “MRO’s or infections”.

80. Mr Reeves then confirmed the booking in the following terms:

Ok, sweet, alright so I’ll just send that one through to despatch for you now. So I confirm

it’s from Glen Innes Hospital at Emergency Department to Armidale Emergency

Department, accepted by ortho registrar, and patient is ready from now… booking

number is 1481416. So the guys at despatch will look at it and get it planned in as soon as

we possibly can for you mate

81. Mr Mohammad Al-Amin was a PTS Floor Operations Co-ordinator at GMBH. His

statement explains that the PTS is used for patients who are clinically stable and within

the scope and capabilities of the PTS. Mr Al-Amin is not clinically trained and explains

that staff at PTS do not have access to patient notes. He states PTS staff do not

determine whether a patient requires urgent transport as PTS staff are not trained to

make such an assessment.

82. Mr Al-Amin states the relevant details for the transfer, including patient requirements,

are provided by the person making the booking. If the booking is for an urgent transfer,

the PTS staff are informed by the person making the booking and the booking request

will contain a notation such as “urgent booking”, “booking is for ambulance”,

“ambulance required” and/or "within 60 minutes”. The PTS booking form does not

include any of these phrases.

83. Mr Al-Amin further explains in his statement:

13. I interpret the Booking Sheet as follows:

a. at 1417 on 31 March 2018, Glen Innes Hospital requested transport to collect

Maureen Smith, with a patient ready time at Glen Innes Hospital of 1420hrs on 31

March 2018;

b. the transport was not booked as urgent; and

c. the patient was to be admitted to the ward of the Armidale Hospital, via its

Emergency Department.

Tab 14B Statement of Mohammed Al-Amin, at [9]-[10]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

14. The middle row of boxes on the Booking Sheet shows a pickup time of between

1410hrs and 1620hrs and a delivery time of 1550hrs to 1900hrs. This is an estimate only

that is pre-generated by the booking system. It does indicate that the PTS vehicle will pick

up the patient in that time. To the best of my understanding the estimate reflects a service

level agreement between PTS and hospitals.

84. Mr Al-Amin later notes that if the Booking Sheet indicated the patient was not suitable

for PTS or required an urgent transfer the usual practice of PTS would be for the

dispatcher to book an ambulance.

85. At 2.30pm ED Triage notes taken by RN MacLean state:

100

“NURSING. PT CARE ACCEPTED BY ARRH ORTHO. TRANSPORT BOOKED

REF NO. 1481416. RN MACLEAN”

86. In his statement, RN MacLean confirms that at around 2.30pm he had been informed

by Dr Manning that Ms Smith was to be transferred to ARRH and that RN MacLean

immediately contacted PTS to make a phone booking. He states he was informed by the

PTS booking officer that they had no vehicle available at that time, but that one would

be dispatched as soon as it became available.

101

87. Dr Manning handwrote a referral to Armidale ED / Orthopaedics Registrar noting:

Problem list:

1. Increasing pain. Multifocal but worse in R knee & sacrum.

2. R Knee swollen & warm

– 10 days post cortisone injection

– I-STAT white cell count ↑ Neuts [?neutrophils] 21.0

3. Acute kidney injury

…

Her R knee has worsening swelling and is warm to touch. Her point of care FBC shows

a significant neutrophilia. Whilst we haven’t documented a fever, given the above she was

discussed with the Orthopaedic Registrar for ? septic joint. He has asked that we transfer

her to Armidale Emergency Department for further assessment. He has asked for fresh

bloods and X-ray. The cultures and bloods we have taken here in Glen Innes will be sent

with her.

102

Ibid, at [13]-[14]

Ibid, at [15]

100

Tab 19 GIDH Records

101

Tab 13A Statement of RN MacLean, at [17]

102

Tab 19 GIDH Records

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

88. The nurse in charge at GIDH between 2:30pm and 11:00pm was RN Adrianna Peitsch,

having taken over from RN Cox who finished at 2.30pm.

103

89. At 2:32pm, according to the joint statement on behalf of HNELHD, NSW Ambulance

(NSWA) and HealthShare NSW (the Joint Response), the notation of “R septic knee

joint” was added into booking 1481416 under the “Patient Comment” field in the Patient

Flow Portal by HNELHD.

104

90. Dr Manning notes that there was a rise in Ms Smith’s heart rate, recorded between

2.45pm and 4.30pm, which remained between the flags and while he was aware of this,

he did not consider it sufficient to require a change of approach.

105

91. At around 3-4pm, Dr Natukokona states that he checked CAP and it indicated that Mr

Smith had not left GIDH so he telephoned PFU to enquire about the reason for Ms

Smith’s delay. He states his impression from that conversation was that she would be

arriving within the next few hours but that she had not yet left GIDH.

106

The CAP search

results do not appear to show this check having been undertaken by Dr Natukokona

under his login,

107

nor do the CAP search results show any CAP searches (under any

108

92. Mr Al-Amin states that the log shows that he and two dispatchers searched for a vehicle

for the transport and could not find one. He states he adopted normal practice when

there was no PTS vehicle available and transferred the booking through the Electronic

Booking Service (EBS) to NSWA. The EBS uses an online portal to manually transfer

the booking to NSWA.

109

93. The booking information forwarded to NSWA noted:

PT 75YO F WGHT: <=150KG NON INFECTIOUS

STRETCHER DIAGNOSIS: OSTEOMYELITIS .. RCV LOCN:

ED, EBS: DX: CHRONIC PAIN

ACCEPTED BY ORTHO REGISTRAR FOR WARD VIA ED

103

Tab 18C Statement of Lisa Ramsland, at [59]

104

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, at [12]

105

Tab 7A Supplementary Statement of Dr Manning, at [13]

106

Tab 9 Statement of Dr Natukokona, at [35]

107

Tab 22 Letter from the CSO, Annexure A CAP Audit Report

108

Letter from the Crown Solicitor’s Office regarding CAP dated 29 October 2021; Tab 22J Letter from the Crown

Solicitor’s Office regarding CAP dated 16 March 2022 and 22M Letter from the Crown Solicitor’s Office

regarding CAP dated 12 May 2022

109

Tab 14B Statement of Mohammed Al-Amin, at [16]-[17]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

PATIENT IS READY FROM 1420

110

94. The forwarded information did not include the note “R septic knee joint”. This

information was contained within an additional comments field and was not forwarded

via the EBS. The Joint Response accepts that this was relevant information which should

have been forwarded to NSWA.

111

95. Mr Al-Amin states the EBS booking was made at 3:13pm and that he notified the

Western Control Centre at NSWA of the transfer at 3:15pm, which is confirmed by the

transcript of calls from PTS in which Mr Al-Amin is recorded as speaking to “Juanita”

at NSWA to advise that PTS had “EBS’d, a patient going from Glen Innes ED to

Armidale ED” before confirming that patient was Maureen Smith.

112

The PTS log

annexed to Mr Al-Amin’s statement confirms EBS at 1513 hours, and ‘WESTERN

ACCEPTED. MA at 1515 hours’.

113

96. PTS telephone transcripts show that Mr Al-Amin then called GIDH at 3:22pm and

spoke to “Amy”

114

and advised the booking had been transferred to NSWA.

115

In his

statement, Mr Al-Amin says he then cancelled the booking at 3:22pm as Ms Smith's

transport had been transferred to NSWA (and that this was the usual process when a

booking is transferred via EBS).

116

97. Since that time, HNELHD and HealthShare NSW have commenced a pilot programme

called ‘Ways of Working’, pursuant to which, if PTS cannot facilitate a booking, the PTS

officer contacts the ward that made the booking and requests them to either reschedule

the non-emergency transfer to another suitable time, or, if the patient must be transferred

via NSWA, the PTS officer will advise them to contact NSWA directly.

117

In a statement

110

Tab 21A Statement of Lauren Mansell, Annexure J Incident Detail Report 60050

111

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, at [14] [Note: CSO commented that “(a) the

medically agreed timeframe is provided by the hospital at the time of booking; and (b) the information provided

by the hospital was that the patient was ready from 1420 with no medically agreed timeframe requested at the

time of booking, in the markup of this Summary of Evidence on 7 September 2021]

112

Tab 22B Statement of Shubjeet Kaur, at [18]-[19] and [27]; Tab 18A Joint Statement of HNELHD, NSWA and

HealthShare, Annexure H Transcripts, p.4

113

Tab 14B Statement of Mohammed Al-Amin

114

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, p.15 the PTS transcript of that phone call

states that it was between Mr Al-Amin and RN Cupitt; Tab 10 Statement of RN Cupitt does not mention that

call or any other related call that RN Cupitt was personally involved in

115

Tab 14B Statement of Mohammed Al-Amin, at [20]; Tab 18A Joint Statement of HNELHD, NSWA and

HealthShare, Annexure H Transcripts, p.5

116

Tab 14B Statement of Mohammed Al-Amin, at [21]

117

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, at [38]-[41]; Tab 22B Statement of Shubjeet

Kaur, at [25]-[26] and Annexure 6

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

on behalf of PTS and HealthShare NSW, Shubjeet Kaur states that this is “significant

change”, noting:

PTS does not have access to patient records and therefore is not the most effective

source of information for any booking being forwarded to NSWA. The new

programme ensures direct communication between the requesting agency (HNELHD)

and the transfer agency (NSWA).

118

98. At 4:49pm, Mr Mark Dunworth of NSWA called Mr Al-Amin from PTS concerning a

booking “from you guys” (i.e. from PTS) and Mr Dunworth stated:

I was just wondering why we got that, there didn’t seem to be anything in the job to

indicate why it would have to go with Ambulance, other than if you just didn’t have a

crew.

99. Mr Al-Amin responded that Ms Smith was suitable for PTS but that “we do not have

anyone in the area … until tomorrow”. Mr Dunworth confirms he was aware of the

policy that NSWA was to provide support to local health districts to achieve timeframes

for inter-facility transport for specialist review within 24 hours, where there was

insufficient PTS crew available to do so and says he “thought that Ms Smith would be

transported by PTS within a 24-hour period”.

119

100. Mr Dunworth said that he had a crew out of town doing a transfer and could not send

an emergency crew out of town simply because there was no patient transport vehicle

available, he said “like if they are going to ED because they need treatment for something

straight away there is a good case to do that” but not if they were going to pass through

ED to “sit on the ward at Armidale until someone could do something”. Mr Dunworth

said he would put the job “on the back burner and it may come back to you tomorrow”.

Mr Al-Amin

replied “ummm, no problem, cool, cool”.

120

Mr Al-Amin states that the

“Log” shows he advised his senior supervisor, the team leader of GMBH, of the

conversation with Mr Dunworth.

121

A copy of the “Log” is annexed to Mr Al-Amin’s

statement and includes a notation stating at 1654 hours “ADVISED TL [Team Leader].

MA.”

122

101. Mr Dunworth accepts that he implied there was limited NSWA capacity to conduct Ms

Smith’s transfer and suggested that he did not have a “spare” crew.

123

118

Tab 22B Statement of Shubjeet Kaur, at [27]

119

Tab 14AB Third Supplementary Statement of Mark Dunworth, at [8]

120

Tab 14 Statement of Mark Dunworth, Annexure A

121

Tab 14B Statement of Mohammed Al-Amin, at [22]-[23]

122

Ibid

123

Tab 14AB Third Supplementary Statement of Mark Dunworth, at [10]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

102. Mr Robert Fairey, A/Chief Superintendent (Western Control Centre NSWA) confirms

that there was capacity for a NSWA transfer at that time.

124

In terms of NSWA crew

availability at around that time, Mr Fairey confirms that:

a. as at 3:15pm that day:

i. there were at least seven crewed NSWA vehicles within 100km of GIDH

that were not then allocated to a job, including one at Glen Innes Station;

ii. a further crew from Armidale Station had just completed a job and was

returning to the station; and

iii. another crew from Tenterfield Station had been assigned to an inter-

hospital transfer but was called off that job shortly after.

125

b. as at 4:49pm that day, at least seven crewed NSWA vehicles remained within

100km of GIDH that were not then allocated to a job, including one at Glen Innes

Station;

126

and

c. as at 5:07pm that day, at least four crewed NSWA vehicles remained within 100km

of GIDH that were not then allocated to a job, including one at Glen Innes Station,

with a further two who “did not attend a case” at that time.

127

103. The PTS phone transcript confirms that GIDH called PTS at 5:03pm on 31 March 2018.

According to the transcript, “Ray” from GIDH spoke to “Shevin” at PTS about the

booking for Ms Smith’s transfer, citing booking number 1481416.

128

This may be the

same call RN MacLean refers to in his statement, which he says he made at around

5.00pm to PTS for a status update on Ms Smith’s transfer.

129

The transcript shows that

“Ray” asked:

Yeah, just want to know how it’s going, I haven’t heard anything from anybody, other

than I’ve been told it’s been booted to Ambulance. Just want to know how long it’s

going to be, we need to get this patient down there

130

104. “Shevin” responded:

124

Tab 21B Statement of Robert Fairey, at [62]

125

Ibid, at [58]

126

Ibid, at [59]

127

Ibid, at [60]

128

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, Annexure H Transcripts, p.6

129

Tab 13A Statement of RN MacLean, at [18]

130

Audio is available at Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, Annexure E

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

Yep, so it has been moved to Ambulance, so I no longer have umm access to what time

they’ll be picking her up. But I can give you the phone number to call to make the

enquiry.

131

105. Mr Al-Amin states that this call is reflected in the Log attached to his statement but that

he was not involved and “did not do anything in relation to the patient for the rest of

my shift”.

132

The Log attached to his statement confirms a notation at 5.05pm:

ADV. PT TO CALL AMBULANCE IN RELATION TO ETA AS BOOKING WAS

NO LONGER WITH US – CB.

133

106. RN MacLean states that he then contacted NSWA and spoke to the Western District

Co-ordinator.

134

At 5:07pm RN MacLean spoke to Mr Dunworth of NSWA. RN

MacLean said to Mr Dunworth that he had “booked or we rang for transport for a patient

to transfer into Armidale a few hours ago”.

135

Mr Dunworth told RN MacLean:

I was talking to Non-Emergency patient transport and they suggested suitable for them

to take. They just don’t have a vehicle and probably won’t have one till tomorrow

morning, so they’re keeping that booking and then once they get a crew tomorrow they’ll

be taking her down to Armidale. So it’ll be tomorrow I’d say.

136

107. RN MacLean asks Mr Dunworth to “hang on for a minute”, there is talking in the

background, after which RN MacLean states:

…Mark I’ve just been speaking to the doctor up here, mate, he wants her to go today

108. Mr Dunworth responds:

Yeah, that’s fine, I can’t send my emergency ambulance out of town to transfer, they’re

actually going to be assisting Tenterfield with a very sick patient coming down to go to

Armidale … so yeah, look, patients that are suitable to go with patient transport have to

go with them, we can’t, we’ll get … anyway, the thing with it is if they are suitable to go

with patient transport, they go with patient transport, not in an emergency ambulance

because we can’t take our emergency resources out of the town for something that isn’t

an emergency because someone who does need it and we’re not there and we’re

transporting a non-emergency case, yeah we can’t explain that so it’ll be, yeah… If the

patient develops any condition that, you know, would then put her outside the flags and

needing immediate transport, it’s only a phone call back to us with all the details and we

can work something out but while they are quite stable and meeting the transport criteria

for non-emergency transport, we can’t put them in an emergency vehicle.

109. NSWA confirms that despite the reference to PTS “keeping that booking”, the booking

was with NSWA as at the time of the call and was not closed with NSWA until 7:38am

the following day.

137

131

CSO has advised that ‘Shevin” is a reference to Charvind Bains

132

Tab 14B Statement of Mohammed Al-Amin, at [24]-[25]

133

Ibid

134

Tab 13A Statement of RN MacLean, at [19]

135

Tab 14 Statement of Mark Dunworth, Annexure A

136

Audio of the conversation is available at Tab 21A, Annexure G

137

Tab 21B Statement of Robert Fairey, at [38]-[39]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

110. Mr Dunworth subsequently stated that, the mention of “sepsis” is “an alarm bell for

me”.

138

He stated that if “sepsis” had been mentioned in his conversations with Mr Al-

Amin or RN Mclean, or if had been contacted later and been advised that the patient’s

condition had deteriorated, he would have reallocated NSWA resources and sent an

ambulance as soon as possible.

139

Mr Dunworth also observed that, in the “Incident

Detail Report” related to the booking, there was similarly no mention of “septic joint”

or “sepsis”, instead there was a statement that Ms Smith was “NON INFECTIOUS”.

Separately, the “Incident Detail Report” also described Ms Smith’s condition as

“osteomyelitis” (an infection of the bone which can develop into sepsis), which was also

mentioned by Mr Dunworth to Mr Al-Amin in the telephone call at 4.49pm.

140

111. Dr Manning states that he was present in ED at the time of a phone call to the

Ambulance service, handwriting the initial referral letter to Armidale ED, but does not

specify the time of that call or who from GIDH made that call.

141

Dr Manning states that

he had the impression that “the Ambulance service was pushing back and did not want

to divert Ambulance officers to transfer Ms Smith”, although he also stated his

recollection that “it was not an immediate “no” from the Ambulance services at that time

and I understood the Ambulance service might still be able to transfer Ms Smith that

day”.

142

Dr Manning states that he instructed the nursing staff at some point during

discussions to advise the Ambulance service that Ms Smith required immediate transfer

that day.

143

112. RN Pietsch was the nurse in charge at GIDH that afternoon and evening. She states that

in her experience “it was not unusual around that time to encounter difficulties at GIDH

securing transport for patients who needed transfer between hospitals”.

144

RN Alyssa

Lowe was a locum nurse working at GIDH at the time and stated “patient transport and

booking ambulances was always difficult in Glen Innes. It was always a long wait to have

ambulances retrieve your patients”.

145

138

Tab 14 Supplementary Statement of Mark Dunworth, at [5] and Annexure A, p.3

139

Ibid, at [10]

140

Ibid, at [6], Annexure B, p.1 and Annexure A, p.1

141

Tab 7 Statement of Dr Manning, at [64]

142

Ibid, at [64]-[65]

143

Tab 7 Statement of Dr Manning, at [67]

144

Tab 13G Statement of RN Adriana Pietsch, at [9]

145

Tab 13H Statement of RN Alyssa Lowe, at [16]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

113. Ms Lauren Mansell, Deputy Director Western Control Centre, NSWA states that NSWA

complied with all policies and procedures in relation to the transfer of Ms Smith.

146

However, she states that:

a. there was a potential system issue that arose during the call at 5.07pm, in which

NSWA was informed that a medical practitioner had requested transfer that day;

147

and

b. there may have been a lost opportunity on the call between Mr Dunworth of

NSWA and GIDH, “or escalation pathways”, to question why Dr Manning wanted

the transfer to occur on Saturday 31 March 2018 (the same day).

148

114. A/Professor Holdgate observed, in connection with the 5:07pm telephone call

transcript, that Mr Dunworth “essentially dismisses the doctor’s request”, also noting it

is “very unfortunate” that Mr Dunworth did not seek further information regarding why

the doctor wanted Ms Smith to be transferred that day.

149

115. Mr Dunworth states that he regrets not making any further enquiry as to why the doctor

wanted Ms Smith transported.

150

116. A/Professor Holdgate refers to the HNELHD and NSWA Interhospital Patient

Transport Process dated December 2017, in particular, the matrix on page two which

states the time to dispatch should be a MAT between the referring clinician (RN or

medical officer) and the accepting medical officer.

151

A/Professor Holdgate concluded

there was clearly no MAT, as both Dr Manning and Dr Natukokona wanted Ms Smith

to be transferred on 31 March 2018, not the following day, and that the failure to consider

the opinions of the referring and accepting doctors with respect to the timeframe for Ms

Smith’s transfer was a breach of policy.

152

117. According to nursing expert RN Eunice Gribbin, there was a failure by nurses to escalate

Ms Smith’s care up the chain of command (to the nurse in charge and/or the hospital

manager covering GIDH over the long weekend) to action a call to NSWA to explain

146

Tab 21A Statement of Lauren Mansell, at [20]

147

Ibid, at [21]

148

Ibid, at [23]

149

Tab 24C Second Supplementary Report of A/Professor Holdgate, p.2

150

Tab 14AB Third Supplementary Statement of Mark Dunworth, at [9]

151

Tab 21A Statement of Lauren Mansell, Annexure O Joint Inter-Hospital Patient Transport Process, p.2

152

Tab 24C Second Supplementary Report of A/Professor Holdgate, p.3

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

the urgency of the request.

153

She opines that nurses should have contacted Dr Manning

and asked that he personally call the NSWA to explain the situation and insist upon

transfer by ambulance that day.

154

118. In his statement, RN MacLean says that after his call with NSWA (i.e. after 5:07pm), he

then called PTS again who told him that Ms Smith would be transferred on the morning

of Sunday 1 April 2018.

155

The telephone call transcripts from PTS do not include a

record of this call and PTS has subsequently advised from its review, there is no further

telephone call identified from GIDH on 31 March 2018 after 5:07pm.

156

RN MacLean

states that he then informed Dr Manning of the updates concerning NSWA and PTS.

157

119. Dr Manning states that he did not know until 5:00pm that “the Ambulance service had

categorically refused to take Ms Smith that day, particularly while her observations were

within normal limits”, and confirms that it was RN MacLean who informed him that

NSWA “had finally categorically said no to Ms Smith’s transfer. I understood they would

only consider taking Ms Smith if she was to deteriorate in her observations (to fall outside

the flags)”.

158

Dr Manning accepts that he should have directly spoken with NSWA to

express the urgency of her transfer.

159

120. At 5.20pm GIDH nursing records document (apparently an entry by RN MacLean):

160

SPOKE TO NSW AMB WESTERN CO-ORD RE TRANSFER OF PT TO ARRH ED.

THEY ADVISE THAT PT IS NOT SUITABLE FOR AND DOES NOT REQUIRE

AMBULANCE TRANSFER THEY HAVE HANDED TRANSFER BACK TO PT

TRANSPORT WHO HAVE NOTHING AVAILABLE UNTIL TOMORROW

01/4/18. I ALSO SPOKE WITH LEE NIXON WHO IS LISTED AT PT’S NOK SHE

IS UNWILLING TO DRIVE PT TO ARRH TODAY [RN MacLean].

121. The Crown Solicitor’s Officer (CSO) has confirmed that “NSWA kept [the] booking on

its system until the following morning”.

161

122. The Inter-Hospital Patient Transport Process policy of HNELHD and NSWA sets out

the policy and guidelines to be followed in relation to transfers such as that of Ms Smith

153

Tab 25 Expert Report of RN Gribbin, p.4

154

Ibid, pp.22-23

155

Tab 13A Statement of RN MacLean, at [20]

156

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare; Tab 22B Statement of Shubjeet Kaur, at [99]

157

Tab 13A Statement of RN MacLean, at [21]

158

Tab 7A Supplementary Statement of Dr Manning, at [19]

159

Ibid, at [22]

160

Tab 19 GIDH Records

161

Tab 21A Statement of Lauren Mansell, Annexure J Incident Detail Report 60050, at [25] states incident closed at

0738 hours on 1 April 2018 [Note: CSO comments in relation to this Summary of Evidence dated 7 September

2021]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

between GIDH and Armidale Hospital.

162

Among other things, it states that the

recognition of the need for NSWA to transfer a patient is outlined against three clinical

criteria,

163

being:

1. The patient has a life-threatening condition that requires emergency transport.

2. The patient is behaviourally unstable requiring mechanical restraint.

3. A patient is assessed as likely to deteriorate and fall outside of “Between the Flags”

criteria.

123. In his supplementary statement, Mr Peter Williams, General Manager, Tablelands Sector,

HNELHD confirmed that HNELHD has reviewed its guidelines around inter-hospital

patient transport, and that the Inter-Hospital Patient Transport Process policy of

HNELHD and NSWA was updated in August 2019, however the criteria for ambulance

versus non-emergency patient transport for inter-hospital transfers did not require

change.

164

124. In March 2020, the HNELHD issued an updated Clinical Policy Compliance Procedure

“Inter-Facility Transfer for Patients requiring Specialist Care”, which states that the

referring medical officer is to “[d]etermine the transport modality and level of clinical

escort required in consultation with the receiving Specialist”.

165

125. Mr Williams states that a medical officer orientation manual has been improved since the

death of Ms Smith.

166

That manual is dated April 2021 and is annexed to Mr Williams’

further statement and contains a section titled ‘Policies and Guidelines’, which states that:

‘Hard copies of MoH and NHE policies and Guidelines exist within departments;

however these may also be accessed through the HNE intranet” and includes a link to a

number of policies.

167

126. The April 2021 manual:

a. does not include reference to the Clinical Policy Compliance Procedure “Inter-

Facility Transfer for Patients requiring Specialist Care”; and

162

Tab 21 NSWA Records, Inter-Hospital Transport Process dated 21 December 2017 (also located at Tab 21A

Statement of Lauren Mansell, Annexure Y and Tab 18 Statement of Peter Williams, Annexure Q2)

163

Tab 21 NSWA Records

164

Tab 18B Supplementary Statement of Peter Williams, at [17]

165

Ibid, at [18] (also located at Tab 18 Statement of Peter Williams, Annexure P2, p.407

166

Ibid at [2] and Annexure A Medical Officer Orientation Manual, p.12

167

Ibid

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

b. includes no other reference describing the obligation on the medical officer

described in the above paragraph.

127. Mr Williams identifies the following as improvements to the April 2021 manual:

a. inclusion of a protocol for suspected septic joint;

b. PFU call protocol;

c. NSWA Escalation Process;

d. clarification concerning the RN in Charge and PFU; and

e. moving the escalation flowcharts into the body of the document.

168

128. In October 2021, a further edition of the medical officer orientation manual was

issued.

169

The manual includes the following relevant additions:

a. a detailed contacts list with a subheading “Interhospital Transfer Key Contacts”;

170

b. reference to an acute care pathway for sepsis available in hardcopy in the ED;

171

c. addition of a section entitled “Escalation of Patient Care to Speciality Services”

outlining the formal network for accessing support and advice;

172

d. addition of a section entitled “Interfacility Transfer for Patients requiring Specialist

Care” which states:

i. the PFU is required to coordinate transfers between 7.00am and 9.00pm

and involves all relevant clinicians;

ii. at all other times the referring clinician co-ordinates the transfer

themselves, directly with the specialist service medical officer;

iii. that once transfer is confirmed, it is the responsibility of GIDH staff (not

PFU) to make the booking; and

iv. includes a reference to the “Inter-facility Transfer for Specialist Care”

policy.

173

168

Tab 18B Supplementary Statement of Peter Williams, at [6]-[7]

169

Tab 22I GIDH Medical Officer Orientation Manual dated October 2021

170

Ibid, p.5

171

Ibid, p.9

172

Ibid, p.10

173

Ibid, pp.10-11

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

e. addition of a section entitled “Role and Responsibilities of the Referring Medical

Officer for InterFacility [sic] Care” which states:

• “Perform a clinical assessment of the patient’s condition, including identifying any

pathology or imaging required to assist in determining clinical status and need for

transfer

• Contact the PFU or specialist service to refer the patient and discuss the plan of

care with the senior specialty clinician

• This includes determination of the Medical Agreed Timeframe (MAT). The MAT

is the time that the patients needs to be at the receiving facility from a clinical

perspective. The referring and accepting medical officers, together, identify the

MAT.

• Determine the transport modality and level of clinical escort required in

consultation with the receiving Specialist

• Contact the PFU/accepting specialist service in the event of clinical deterioration

while awaiting transfer for, updated treatment advice and reassessment of the

urgency for transfer

• Maintain responsibility for the patient while patient transfer is pending

Exception: Responsibility is transferred to the Retrieval Service when they take

over patient care”

174

f. addition of a section entitled “Patient Transport Delays” prompting the use of the

existing NSWA escalation flowchart;

175

g. addition of sections outlining the availability of radiology and pathology;

176

h. inclusion of a PFU three-way conference call visual aide;

177

and

i. inclusion of the Adult Sepsis Pathway tool.

178

129. The October 2021 manual does not include copies of the policies identified within the

body of the manual as annexures. Alternatively, the policies appear to be hyperlinked to

a NSW Health intranet page.

Ms Smith’s care after it was clear there would be no transport on 31 March 2018

130. Having been advised that Ms Smith was not going to be transported to ARRH that day,

in A/Professor Holdgate’s opinion:

a. the advice given by Dr Natukokona to Dr Manning at this point to withhold

antibiotics was inappropriate as it meant that, even with a transfer early the

174

Tab 22I GIDH Medical Officer Orientation Manual dated October 2021, p.11

175

Ibid, pp.12-13

176

Ibid, p.14

177

Ibid, p.20

178

Ibid, pp.22-25

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

following morning, the patient would face a delay of nearly 24 hours prior to

diagnosis and treatment which is not clinically acceptable;

179

b. the most appropriate advice to Dr Manning would have been to aspirate the knee

at GIDH and then commence antibiotics;

180

c. in circumstances where Dr Manning did not have the skill or experience to perform

a knee aspiration, Dr Manning and Dr Natukokona should have liaised with

NSWA to arrange an urgent ambulance transfer to ARRH;

181

d. it was not appropriate for family or friends to transfer Ms Smith;

182

and

e. if an ambulance transfer still could not occur, antibiotics should have been

commenced.

183

131. Further, A/Professor Holdgate opines that, upon learning that Ms Smith was not to be

transferred that day, Dr Natukokona should have:

184

a. discussed with Dr Manning his ability to perform an aspiration of the knee joint

and, failing the ability to execute of that procedure by Dr Manning, Dr Natukokona

should have advocated strongly for Ms Smith to be transferred to ARRH that day;

b. recommended that antibiotics be commenced at GIDH; and

c. at a minimum, discussed the case with his consultant orthopaedic surgeon to get

further advice in relation to Ms Smith’s care.

Second review by Dr Manning

132. RN Mclean states that, at Dr Manning’s instruction, he arranged for Ms Smith to be

transferred to a ward bed overnight and handed over to one of the ward nurses at about

5:50pm.

133. At 6.00pm, GIDH nursing records (apparently an entry by EN Amy Cupitt):

185

Admission attended in ED. High Falls Risk. Handed over to evening staff – please

attend FRAMP. Pt also confused @ times. IV in progress. Transferred to ward at

18.10hrs.

179

Tab 24A Expert Report of A/Professor Holdgate, p.7 at [3.3]

180

Ibid

181

Ibid

182

Ibid, p.6 at [2.6]

183

Ibid, p.7 at [3.3]

184

Tab 24B Supplementary Report of A/Professor Holdgate, p.4 at bullet point 1

185

Tab 19 GIDH Records

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

134. According to the statement of EN Cupitt, at approximately 6.00pm, EN Cupitt

completed the Adult Inpatient Admission Form and Risk Assessment Form and in doing

so, asked Ms Smith if she had a current history of MRSA, vancomycin-resistant

enterococcus (VRE), to which Ms Smith answered ‘No’.

186

135. Also at 6.00pm, clinical notes reflect that Dr Manning had reviewed Ms Smith again

noting:

75♀ ? Septic R knee

accepted for transfer to

armidale

Ambulance unable to transport

Patient flow aware

No family or friends available or willing

One friend who rang in to enquire declined as they had spent the last 3 days with her

R knee remains tender, swollen and warm to touch

Confusion more noticeable

187

136. Dr Manning clarifies that his reference to “patient flow” was a general term for the

administration that co-ordinated the interhospital patient transfers either by ambulance

or by PTS.

188

137. Further, Dr Natukokona says in his statement that at 6.00pm, Dr Manning and PFU rang

his mobile telephone in a three way link, in which PFU advised him that Ms Smith would

be admitted overnight at GIDH and transferred to ARRH first thing the following

morning, a decision which Dr Natukokona says he questioned before advising that Ms

Smith should be transferred immediately to ARRH.

189

Dr Manning says that he does not

recall any “three way” phone call.

190

Ms Welfare says in her statement that if a three way

conference call had taken place it would have been documented in the PFU database

progress notes.

191

186

Tab 10 Statement of Amy Cupitt, at [14]

187

Tab 19 GIDH Records

188

Tab 7A Supplementary Statement of Dr Manning, at [15]

189

Tab 9 Statement of Dr Natukokona, at [37]

190

Tab 7 Statement of Dr Manning, at [122(a)]

191

Tab 22A Statement of Lisa Welfare, at [6]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

Second contact with orthopaedic registrar at ARRH

138. Further notes by Dr Manning on 31 March 2018 appear to be the final entry in the GIDH

Clinical Notes before 1 April 2018 and document a discussion with Dr Natukokona.

Those notes read:

…

Patient flow advise transport available tomorrow

Plan. Admit here.

D/w Ortho Registrar

-request no abs

-monitor o’night

-they want to tap knee

Continue IV fluids

analgesia

reculture if febrile

repeat POC FBC + Chem 8

tomorrow

192

139. Dr Manning states that at no point in either discussion with Dr Natukokona did Dr

Natukokona ask Dr Manning to “perform the joint aspiration procedure, as he did not

agree with my assessment of a septic process. Dr Natukokona wanted to see Ms Smith

and perform the aspiration himself if he felt it was necessary”.

193

140. The noted conversation with the “Ortho Registrar” was the subject of oral evidence.

141. An explanation of the records was sought in oral evidence along with what was conveyed

to nursing staff.

142. In his statement, Dr Manning said that he told [unnamed] nursing staff that if, at any

time during the evening, they were worried about Ms Smith, or if Ms Smith deteriorated,

developed a fever/temperature, to contact him immediately. He stated that he expected

Ms Smith would remain under close and regular observation by nursing staff but accepts

in hindsight he should have specifically documented and advised nursing staff to keep

Ms Smith under close observation, at least 4 hourly.

194

192

Tab 19 GIDH Records [Note: these notes begin at the top of a page without specifying the exact time, although

they appear to be a continuation of Dr Manning’s 6.00pm notes mentioned in paragraph [133] of this Summary

of Evidence]

193

Tab 7A Supplementary Statement of Dr Manning, at [29]

194

Ibid, at [82]-[84]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

143. At 7.20pm, an “Afterhours Admission / Transfer / Discharge Form” was completed in

relation to Ms Smith, noting admission at GIDH and transfer to ward at 1900hrs,

“Admission Reason: Fall”.

195

144. At 9.15pm nursing recorded (apparently an entry by RN Alyssa Lowe):

196

Analgesia given with good effect. Pt refused to be turned @ 2030. IVF in progress for tx

to armidale tomorrow for ortho review. Vitals stable, afebrile.

145. Observations were recorded on seven occasions between 11.40am and 8.45pm on 31

March 2018 and most signs remained within normal limits although, according to

A/Professor Holdgate, the “heart rate was persistently at the upper end of the normal

range”.

197

146. In her expert nursing reports, RN Gribbin states that there was a failure to closely

observe and monitor Ms Smith. RN Gribbin was only able to identify two partially

entered, hourly rounding checks overnight on 31 March 2018. RN Gribbin opines that

nurses would or should have known to closely monitor Ms Smith’s observations

overnight every hour and that this was particularly important in Ms Smith’s case, in light

of her suspected septic right knee and acute kidney injury, which a reasonably competent

nurse would have identified as issues which can lead to rapid deterioration requiring close

and regular monitoring.

198

147. The nurse in charge at GIDH from 10.45pm to 7.15am the next morning was RN

Heather Conyard, having taken over from RN Adrianna Peitsch who finished at

11.00pm.

199

148. In her statement, RN Conyard recounted that at 11pm, during her first round of the

patients following handover, she observed Ms Smith to be sleeping, and that hourly

rounds continued to be performed on the patients, including Mrs Smith throughout the

shift.

200

195

Tab 19 GIDH Records, ARRH Afterhours Admission / Transfer / Discharge Form dated 31 March 2018

196

Tab 19 GIDH Records

197

Ibid; Tab 24A Expert Report of A/Professor Holdgate Report, at [1.13]

198

Tab 25 Expert Report of RN Gribbin, pp.4-5, 21

199

Tab 18C Statement of Lisa Ramsland, at [59]

200

Tab 12 Statement of RN Conyard, at [10]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

D. 1 APRIL 2018: GIDH CARE

149. At 6:45am vital signs were taken and at 7.00am on 1 April 2018 EN Jeanette Murphy

who recorded:

Pt observed to be talking in sleep overnight. Obs attended and remain between the flags

as per SAGO chart. Pt is unable to swallow paracetamol this am, not able to use straw

for fluids -not understanding what to do with this action. Reported to RN Conyard

(Murphy EEN)

201

150. Observations recorded at 6:45am are recorded as follows:

RR 18bpm, SpO2 98% on nasal prongs, BP 128/63, HR 100bpm and regular,

neurological observation level was alert, T = 36.9, pain level “R” for resting.

202

151. In her statement, EN Murphy stated that:

I was not sure why Mrs Smith could not use the straw, and considered that it was

possibly because I had woken her or because her mouth was too dry

203

152. RN Conyard said, in her statement, that:

Ms Smith was orientated as to person and place but had difficulty sucking water through

a straw so she could take her medication. This was overcome by EN McDonald

assisting Mrs Smith to drink from a glass

204

153. A/Professor Holdgate opines that the above note recorded by EN Murphy indicates that

Mrs Smith was confused and unable to coordinate drinking from a straw.

205

154. RN Gribbin observes that no fluid balance chart was maintained in relation to Ms Smith,

and the above entry (which she notes to have been recorded at 6.45am) was the only

observation recorded since 8.45pm on 31 March 2018. No further observations were

recorded for the remainder of Ms Smith’s time at GIDH, constituting a delay of ten

hours overnight without recorded observations and a further delay of eight hours after

the single recorded observation referred to above,

206

which RN Gribbin states would

have made early detection difficult.

207

155. RN Gribbin also states that Ms Smith’s decline on this morning required an immediate

response by way of escalation up the chain of command to expedite an appropriate

201

Tab 19 GIDH Records, p.28; Tab 13 Statement of RN Murphy, at [15]

202

Tab 13 Statement of RN Murphy, at [13]; Tab 19 GIDH Records, p.28

203

Tab 13 Statement of EN Murphy, at [16]

204

Ibid, at [12]

205

Tab 24A Expert Report of A/Professor Holdgate, at [1.14]

206

Tab 25 Expert Report of RN Gribbin, pp.4 and 17

207

Tab 25A Supplementary Report of RN Eunice Gribbin, at [1.1]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

response

208

but states that, despite Ms Smith’s apparent decline in condition, the nurses

failed to call Dr Manning or escalate Ms Smith’s care up the chain of command.

209

156. The nurse in charge at GIDH from 7.00am was RN Cox, taking over from RN Conyard

who finished at 7.15am.

210

157. At 7.22am, nursing recorded:

Phone call from Mark, After Hours Bed Manager in Armidale Hospital, received 0655

hrs. Advised that on Pt being transported to ARRH today – pending transport

confirmation – for staff to contact ARRH ED to hand Pt over as it is unclear if any

handover to ARRH staff has been attended from nursing staff

211

158. Around this time, PFU called GIDH to advise that there was no booking. A notation at

7.41am in the PFU notes states the following (which may be a later entry for that call,

not reflecting the actual time of the call):

“(Stacey Greentree) Pt not moved overnight-ward following up”

159. At 7.30am, GIDH nursing recorded:

212

Pt flow manager Stacey called regarding no booking. Booking confirmed – rebooked for

today. Booking # 1481727 ?10am, not confirmed time at this stage but will be

transferred today

160. At 7:28am, PTS telephone records show a call from GIDH to PTS in which it appears

that “Hannah McCarthy” who identifies herself as a nurse from GIDH, speaks to “Stu”

(understood to be Mr Stuart Reeves) at PTS. Some of that conversation is set out as

follows (with minor interjections and comments represented by ellipses). Ms McCarthy

said:

I’ve got a patient here that we’ve got written down for transfer, er, transport to Armidale

Hospital today. I’ve just been contacted through Patient Flow saying that no booking has

been made for the same … and I was wondering if it is possible if we could try and

organise something

213

161. After some discussion to ensure identification of the patient and locations, Mr Reeves

confirmed:

yes there was a booking made, um it was created on the 31

which was yesterday at 2:17

in the afternoon by myself from Ray … um, I made that booking, and she was getting

accepted by the ortho registrar down at the ward via ED … and it was transferred to

NSW Ambulance

208

Tab 25A Supplementary Report of RN Eunice Gribbin, at [1.2]

209

Ibid, p.5

210

Tab 18C Statement of Lisa Ramsland, at [59]

211

Tab 19 GIDH Records

212

Ibid

213

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, Annexure H Transcript, p.7 and Annexure F

Audio

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

162. The transcript then refers to “GI” (which may be a reference to GIDH and therefore to

Ms McCarthy), who said:

Well, NSW Ambulance had actually rung back, and this was documented at 1720 …

163. Ms McCarthy continued:

… and Ray’s written this, that spoke to NSW Ambulance, Western Coord, retransfer of

patient to Armidale. They advised that the patient is not suitable and does not require

Patient Transfer … and they have handed patient to Patient Transport, who have

nothing available until tomorrow … you can redo that one?

164. Mr Reeves replied:

yeah I can certainly re-book it, I’m just having a look at the log notes here. Yeah the

booking was forwarded at 3:13 … so they’ve obviously sent it over. There might have

been a capacity situation, as to why they couldn’t, why we couldn’t actually do it at that

time … so I’ll create a new form …

165. Ms McCarthy informed Mr Reeves:

Um, she does have MRSA … and she is quite off with the fairies

166. Mr Reeves asked:

Is that delirium that she has, is it a delirium or is she cognitively impaired?

167. Ms McCarthy replied:

It seems to be more of a delirium at this point, and it has been noted that she’s had this

on admission

168. Mr Reeves responded:

Ok, no worries at all, that’s fine, MRSA, chronic pain, delirium. [inaudible] got

osteomyelitis. And there’s no other history with her?

169. Ms McCarthy replied:

no, I think um the reason why she’s got chronic pain and everything stems from having a

car accident quite a few years ago, and she’s had that sort of, um, then medication like

dependency from there…

170. After some formalities, Mr Reeves confirmed:

so I’ve got that in, and that’s booked in patient ready from now, and the booking

number is 1481727 [repeated]. Yep so, in that region, the earliest vehicle we can put her

on is a 10 o’clock car

171. Dr Manning agrees, with the benefit of hindsight and with reference to RN McCarthy’s

reference to Ms Smith being “off with the fairies”, that Ms Smith’s level of confusion at

that time indicated a clinical emergency. He states that at the time, he did not appreciate

the significance of the delirium in the context of observations otherwise being “between

the flags”.

214

Tab 7A Supplementary Statement of Dr Manning, at [35]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

172. Ms Ramsland confirms that:

The Delirium Clinical Care Standards policy and the Prevention, Recognition and Management of

Delirium policy compliance procedure (PCP) require for patients at risk of delirium to be

screened using the assessment tool. All patients over the age of 65 years who present to

hospital and have a cognitive impairment or recent change in behaviour or thinking are to

undergo early screening using one of the multiple tools listed in the PCP. Infection and

pain are listed in the PCP as precipitating factors for delirium. The patient met the criteria

for being at risk, and therefore should have undergone assessment for Delirium using the

Delirium Risk Assessment Tool (DRAT) within 24 hours of presentation/admission. This

tool subsequently recommends further investigations if there is a change in behaviour and

ongoing daily monitoring of a patient’s condition using the Confusion Assessment

Method tool.

215

173. NSWA confirms that the booking was not transferred from NSWA to PTS but states

that “at 0728 hours on 1 April 2018, HNELHD rebooked the transfer with PTS”.

216

174. At 7:31am, PTS Booking Form 1481727 shows that a booking was made by “Hannah”

to transfer Ms Smith from GIDH to ARRH. The Joint Response states that this

telephone call was made at 7:28am.

217

Booking Form 1481727 notes, among other

things:

(MRSA) Methicillin Resistant Staphylococcus Aureus

Is the Patient Between the Flags? / Yes

DX: OSTEOMYELITIS

HX: MRSA // CHRONIC PAIN // DELIRIUM

ACCEPTED BY ORTHO REGISTRAR FOR WARD VIA ED

R septic knee joint

Pickup Time 01/04 07:20 – 09:30

Delivery Time 01/04 09:00 – 12:10

175. The booking form does not make any reference to the booking being “urgent” or any

similar statements.

176. At 7:32am, transfer 1481727 was allocated to a PTS vehicle.

218

177. At 7.36am, Mr Mark Dunworth of NSWA called PTS and spoke to someone he called

“Tooba”, concerning Ms Smith’s transfer.

219

Mr Dunworth said:

“got a job that we got from you guys yesterday only because you had no vehicles. It was

a Glen Innes to Armidale and I know the guys were going out – they were doing a Glen

215

Tab 18C Statement of Lisa Ramsland, at [60]

216

Tab 21B Statement of Robert Fairey, at [40]-[41]

217

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, at [21] and Annexure G Booking 1481727

218

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, at [23]

219

Tab 14 Supplementary Statement of Mark Dunworth, Annexure A Transcript, pp.5-6

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

Innes out to Vegetable Creek and then bringing a Vegetable Creek back into Glen Innes

umm and so I thought this one might just umm fit in perfectly. It’s - ”

178. “Tooba” interrupted to say:

“just before you go on, maybe I’ve got it already because that car is full now”

179. Mr Dunworth and “Tooba” then confirmed that they were both talking about “Maureen

Ann Smith” and ended the conversation.

180. At 7:38am, NSWA Incident Report Details records “CONFIRMED GOING WITH

NEPT”.

220

181. Also at 7:38am, NSWA Incident Report Details further records “Incident has been

closed.”

221

182. The next apparent notation after 7:30am in the GIDH Clinical Notes is by Dr Manning,

showing that at an unspecified time on 1 April 2018 he reviewed Ms Smith and recorded:

75♀ ↑ pain

confusion

swollen R knee post

cortisone injection

AKI [acute kidney injury]

?Septic R knee

no transfer options to Armidale

Ortho has requested no abs pending their review

Full bloods +cultures taken here

But unable to transfer for analysis

on slow IV fluids …

222

183. Also, at an unspecified time on 1 April 2018, possibly at the same time and as the

remainder of the notes immediately above, Dr Manning’s notes record in relation to Ms

Smith:

… O/E HR 100 128/63

Clear HSDNA

Soft

no mass

R Knee ↑ swelling

tender

warm

220

Ibid, Annexure B Transcript, p.2; Tab 21A Statement of Lauren Mansell, Annexure J Incident Detail Report

60050

221

Ibid

222

Tab 19 GIDH Records

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

Imp: Delirium

+ raised WCC

? Septic knee

(not clear cut but no other source)

limit investigations available locally to progress diagnosis and were unable to transfer

Plan: T/F today

Urine MCS

CXR to complete septic screen

await bloods

if unable to transfer will need MX [management] soon

223

184. A further note by Dr Manning was added to the handwritten referral prepared for ARRH

that morning also at an unspecified time, which reads:

Maureen has remained afebrile but increased delirium and the swelling in the right knee

has increased.

She is having CXR [?chest X-Ray] & urine studies but without formal bloods our ability

to further identify the source has been limited.

As per orthopaedics we have held off antibiotics.

224

185. Dr Manning states that he recalls looking at the Standard Adult General Observation

chart (SAGO chart) during his ward round that morning and noticed there were no

observations performed overnight. He recalls the nurse with him also commenting on

this and informing him it would be followed up.

225

Dr Manning accepts that he should

have recorded the frequency of observations into Ms Smith’s patient file.

226

186. A/Professor Holdgate states that given the ongoing delays in the transfer, antibiotics

should have been administered on the morning of 1 April 2018 and that this would have

probably increased Ms Smith’s chances of survival,

227

although it is not possible to

quantify that increase.

228

187. A/Professor Holdgate further opines that when Ms Smith did not arrive at ARRH during

the morning, Dr Natukokona should have actively pursued her whereabouts given his

awareness of her possible septic arthritis and given that he had advised (at least, according

to Dr Manning’s contemporaneous notes) that antibiotics should not be administered.

A/Professor Holdgate also opined that it was not Dr Natukokona alone who was

responsible for pursuing the progress of Mrs Smith’s transfer.

229

223

Tab 19 GIDH Records

224

Tab 19 GIDH Records

225

Tab 7A Supplementary Statement of Dr Manning, at [32]

226

Ibid, at [33]

227

Tab 24A Expert Report of A/Professor Holdgate, at [3.4]

228

Ibid, at [8.1]

229

Tab 24B Supplementary Report of A/Professor Holdgate, p.4 at bullet point 2

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

188. At 9.30am, x-rays were taken of Ms Smith’s chest and right knee.

230

189. At 10.00am, according to her statement, RN Carol Tierney from PTS arrived with Rachel

Margery, Patient Transport Officer (PTO), at GIDH for the purpose of transferring a

different patient to Emmaville Multipurpose Service and during that attendance, became

aware of the transfer of Ms Smith to ARRH.

231

In the Joint Response, it is stated that the

PTS crew “first transferred a patient from GIDH to Vegetable Creek Multipurpose

Service at Emmaville on the morning of 1 April 2018” in response to a booking that was

made the previous morning at 11:31am.

232

190. At 11.00am Ms Smith was documented by EN Cupitt as confused and incontinent of

urine. A Mid-Stream Urine test was collected.

233

191. At 12.15pm nursing records noted (apparently by RN Jodie Dijkstra):

234

Ice applied to pt’s R) knee helping with pain & inflammation. Pt says that her left arm &

leg felt “heavy” Pt also complained of painful heels. Heel pads & bandages applied.

Remains awaiting T/F – resting comfortably otherwise.

192. Dr Manning states that he was passing by Ms Smith’s room at around 12:30pm to review

another patient and was surprised and frustrated to see that she had not been transferred

earlier that day. He states he expected to be notified by nursing staff if she was not

transferred as planned. Dr Manning said he was told by the ward nurse that there was a

higher priority patient that required transfer that morning but that the transport officer

was back on site at the hospital having a short mandated break.

193. RN Gribbin states that the failure by nursing staff to have engaged in close monitoring

and recording of observations, along with failing to make Dr Manning aware of the

delayed transportation and refusal of NSWA to accept Ms Smith’s transfer, was a missed

opportunity for urgent action to be taken by Dr Manning.

235

E. 1 APRIL 2018: PTS ARRIVAL AT GIDH AND TRANSFER TO ARRH

194. According to the Joint Response, the PTS crew returned to GIDH at 1:25pm and

commenced a mandated break.

230

Tab 19 GIDH Records

231

Tab 16 Statement of RN Tierney, at [7]

232

Tab 18A Joint Statement of HNELHD, NSWA and HealthShare, at [26]

233

Tab 19 GIDH Records

234

Ibid

235

Tab 25A Supplementary Report of RN Eunice Gribbin, at [1.3]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

195. According to her statement, at an unspecified time RN Tierney and her colleague

returned to GIDH from two other jobs involving Emmaville Multipurpose Service.

236

Upon arrival, she observed Ms Smith sitting up in bed, she was pale, “a little bit restless

and rubbing her ankle”. RN Tierney states that the nursing staff advised her that Ms

Smith’s diagnosis appeared to be sepsis.

237

196. RN Gribbin states that a full set of observations is required prior to any form of patient

transfer but that this was not done in relation to Ms Smith prior to her transfer.

238

197. RN Tierney states she reviewed Ms Smith’s paperwork upon arrival and noticed that

observations had not been recorded since around 6.30am and requested that those be

performed noting in her statement that temperature, blood pressure and pulse were

within normal limits, but her oxygen saturation was low.

239

The observations do not

appear to be recorded in the medical notes. RN Tierney requested oxygen to be given to

Ms Smith and recalls that this was applied by simple face mask and that, prior to leaving

the ward, her oxygen saturation had gone up over 90%.

240

198. At 1.40pm Morphine was administered.

241

In transferring Ms Smith to the stretcher, RN

Tierney states that Ms Smith remained a little restless and as a result, RN Tierney asked

if it was possible to have a bit more pain care for Ms Smith. RN Tierney further states

that the “nurses consulted with the doctor in the ED, and 2.5mg morphine IV was

ordered and given”.

242

Dr Manning states that he ordered the morphine without

reviewing Ms Smith because he was with another patient in the ED and unable to leave

the ED. He states that, with the benefit of hindsight, he should have gone to review Ms

Smith and taken her observations before doing so.

243

199. Patient transport officer (PTO) Rachel Margery recalls that RN Tierney said of Ms Smith

as they prepared for transfer, “she’s not well” and words to the effect for Ms Margery to

get to Armidale as quickly as possible.

244

236

Tab 16 Statement of RN Tierney, at [8]

237

Ibid, at [9]

238

Tab 25 Expert Report of RN Gribbin, p.17

239

Tab 16 Statement of RN Tierney, at [9]

240

Ibid, at [9] and [13]

241

Tab 19 GIDH Records

242

Tab 16 Statement of RN Tierney, at [11]

243

Tab 7A Supplementary Statement of Dr Manning, at [34]

244

Tab 16B Statement of Rachel Margery, at [8]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

200. According to GIDH records, Ms Smith’s transfer to ARRH commenced at 2.00pm.

245

201. The handover information provided (Handover Printout)

246

confirms that the transfer

at “pickup” was affected as between nurse “Amy” (understood to be EN Amy Cupitt)

and PTS staff “Carol” (understood to be RN Carol Tierney). The Handover Printout

included the following information:

a. in response to “Are there any concerns regarding clinical deterioration for this

patient during transport?”, “No”;

b. confirmation of an altered cognitive state (e.g. Confusion), and “anxious

reassurance given”;

c. confirmation of infection risk;

d. confirmation that the PTS crew had assessed Ms Smith as suitable for transport

with PTS; and

e. most recent observations were between the flats “YES”.

202. At 2.00pm, nursing records (by RN McLoughlin) note that blood results were returned

by telephone from Tamworth pathology in relation to samples collected the previous

day, demonstrating:

a. a white cell count (WCC) of 29.6 which was, according to A/Professor Holdgate,

“very high”;

247

b. high C-reactive Protein (CRP), later determined to be 403: also “very high”

according to A/Professor Holdgate

248

;

c. potassium of 6.1: according to A/Professor Holdgate “moderately elevated”;

249

d. creatinine of 196: according to Professor Rawlinson

250

“raised Creatinine”; and

e. GFR at 23 ml/min: according to Professor Rawlinson, “decreased”.

251

203. A/Professor Holdgate confirms that both WCC and CRP are general tests, results of

which can be raised for many reasons but most commonly in the presence of infection.

245

Tab 19 GIDH Records

246

Tab 22E HealthShare Handover Printout

247

Tab 19 GIDH Records; Tab 24A Expert Report of A/Professor Holdgate, at [1.16]

248

Ibid

249

Ibid

250

Tab 23 Expert Report of Professor Rawlinson, p.8 at bullet point 4

251

Ibid

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

Raised WCC and CRP indicates significant infection but does not differentiate between

localised or generalised infection. Ms Smith’s results were consistent with both septic

arthritis (restricted to the joint) or generalised sepsis (throughout the body). However,

she states that, in conjunction with her increased confusion during the morning, the

significantly raised WCC and CRP would be supportive of the presence of generalised

sepsis.

252

204. Dr Manning states that he was not made aware of these pathology results at the time

they arrived and did not learn of them until between 5.30 to 6pm that day. As he did not

have access to Auslab, he requested the RN MacLean access Auslab on his behalf to

access the results at or around that time.

253

205. Dr Manning states:

Had I known that Ms Smith had a CRP of 403, at any stage, I would have immediately

changed my approach, as a CRP that high would have supported a diagnosis of sepsis. I

would have commenced Ms Smith on antibiotics immediately, regardless of other

circumstances.

254

206. At 3.00pm nursing notes state (apparently a note by EN Cupitt):

255

Pt transferred to ARRH via pt t/p @1400hrs. Analgesia & anti-emetic given prior to

leaving. Pt extremely anxious – IVF in progress. Handover given to ARRH ED staff on

departure

207. RN Tierney states that:

a. Ms Smith was alert and conversing throughout the trip, apart from being “a little

confused” when talking about her children at one stage, but otherwise alert;

256

and

b. about 10 minutes from ARRH, Ms Smith was a little bit restless and said she had

a backache.

257

208. RN Gribbin notes that clinical observations where not documented during the transfer

and this is not consistent with peer professional opinion as competent clinical practice

at the time.

258

252

Tab 24B Supplementary Report of A/Professor Holdgate, p.2

253

Tab 7A Supplementary Statement of Dr Manning, at [7]

254

Ibid, at [8]

255

Tab 19 GIDH Records

256

Tab 16 Statement of RN Tierney, at [16]

257

Ibid, at [17]

258

Tab 25A Supplementary Report of RN Eunice Gribbin, at [2.2]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

F. 1 APRIL 2018: ARRIVAL AT ARRH, HANDOVER AND TREATMENT

Arrival at ARRH

209. ARRH records show that Ms Smith arrived at 3.14pm and was triaged as ATS2.

259

210. At 3.15pm, ARRH ED Triage Nurse Notes state in typeface:

260

Pt BIB Community transport, presented last night with chronic right shoulder and knee

pain.

Pt for admission via ortho reg for ? septic right knee post cortoissone [sic] injection last

week.

OE: Pt not abke [sic] to answer questions, cold perioherally [sic], looks very unwell,

offloaded to be for further assessment, appears delusional to community nurse.

211. And in handwriting:

“T/F from Glen Innes Hospital with ? septic (R) knee

On arrival to ED pt was pale and nonresponsive

Offloaded to resus, seen by Dr Young

Warm to touch, cap refill 4 sec …”

Handover / Triage – timing and location

212. At or shortly after the time of arrival, RN Tierney executed handover with the triage

nurse, RN Joanne Mulvey, in the location RN Mulvey identified as the green boxed area

on the map below. While handover occurred, Ms Smith was in the “Ambulance Triage”

area, outlined in red below, with PTO Rachel Margery and without any medical staff in

attendance.

259

Tab 20 ARRH Records, pp.6, 11

260

Tab 20 ARRH Records, p.11

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

213. PTO Margery states that Ms Smith was placed “to the right of the words “Ambulance

Triage 0-045” on the above map, within the red outline.”

261

RN Mulvey states, by

marking on a map, that Ms Smith was left within the outlined Ambulance Triage area

but to the left of the central dotted line.

262

214. In the PTS incident report, the ‘notifier’ is identified as RN Tierney and the following

note is recorded under ‘incident description’:

263

I left Mrs Smith, on the stretcher in the triage bay after we made her comfortable

rearranging her position, with our Driver at 1514hrs and went the separate room to give

handover to the triage nurse Jo. The time of 1514hrs is the record on the triage notes.

215. The PTS incident report recorded that PTO Margery had stayed with Ms Smith during

the time in which RN Tierney had conducted the handover.

264

PTO Margery confirms

this in her statement.

265

216. PTO Margery recalls that RN Tierney did a set of observations on Ms Smith upon arrival,

before leaving the patient through the door between “Office Write-up (AMB) 0-044”

261

Tab 16B Statement of Rachel Margery, at [12]

262

Tab 11B Supplementary Statement of RN Mulvey, at [5]

263

Tab 22F Patient Transport Services Incident Report

264

Ibid, p.3 under the heading “Senior staff member”

265

Tab 16B Statement of Rachel Margery, at [13]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

and “Reception/Clerical/Security/Copy 0-002” (that door is circled in blue on the map

of ARRH above) to undertake the handover.

266

217. RN Mulvey has indicated that the handover occurred at the location of the green outline

in the map above.

267

218. According to RN Mulvey, the handover commenced at 3:15pm.

268

It continued for a

“short period of time” but she does not recall how long the handover had been going

for before she and RN Tierney returned to the Ambulance Triage area to see Ms Smith

because “it became evident that [she] needed clarification on Ms Smith’s current

condition”.

269

219. According to RN Tierney, the handover commenced at 3:14pm and ended at 3:25pm

or 3:26pm. RN Tierney states that she is aware of the timing of the handover having had

reference to the incident report (which records the time of Ms Smith’s arrival at ARRH

as 3:14pm) and the audio of a subsequent telephone call she made to PTS Sydney hub.

270

In that telephone call, RN Tierney reported back to PTS that she had been in triage for

12 minutes while PTO Margery was with Ms Smith.

271

220. PTO Margery states that RN Tierney returned to Ms Smith at 3:26pm with a nurse from

ARRH.

272

221. RN Tierney states that, when she and RN Mulvey returned, Ms Smith appeared to be

sleeping and responded only with “a noise that sounded like a grunt or a groan” when

the triage nurse (presumably RN Mulvey) addressed her.

273

The PTS incident report

includes the following related note:

274

Around 1525hrs the triage nurse and I came out of the room to speak to Mrs Smith. Mrs

Smith only grunted to Jo then there was no more response from her. Mrs Smith face was

very pale in colour.

266

Tab 16B Statement of Rachel Margery, at [13]

267

Tab 11B Second Supplementary Statement of RN Mulvey at [6] and Annexure A

268

Tab 11A Supplementary Statement of RN Mulvey, at [5]; Tab 11B Second Supplementary Statement of RN

Mulvey, at [6]

269

Tab 11B Second Supplementary Statement of RN Mulvey, at [6]

270

Tab 16A Supplementary Statement of RN Tierney, at [20A] and Annexure E Transcript

271

Ibid, Annexure E Transcript, at p.2

272

Tab 16B Statement of Rachel Margery, at [15]

273

Tab 16 Statement of RN Tierney, at [21]

274

Tab 22F Patient Transport Services Incident Report

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

222. RN Mulvey states that it is not possible to bring a patient on a stretcher into the “Patient

Transport and Triage Area”.

275

223. RN Sillitoe states that normal practice for a patient arriving to ED via inter-hospital

transfer “would have been to triage them in the designated Ambulance Bay within the

department.”

276

RN Gribbin states that handover ought to have been conducted at the

bedside.

277

224. The “Clinical Handover – Standard Key Principles” policy in place at the time of the

handover states the handover place should be:

“In the patient’s presence, where appropriate (bedside handover).”

278

225. That policy also states:

“Where the condition of a patient is deteriorating: Escalate the management of these

patients as soon as a deterioration in condition is detected.”

279

Handover / Triage – notes

226. The Handover Printout confirms that the transfer at “destination” was affected as

between PTS staff “Carol” (RN Carol Tierney) and nurse “Jo” (RN Joanne Mulvey). The

Handover Printout included the following information:

280

a. the “current diagnosis” provided was “chronic pain”. RN Tierney has stated she

acknowledges she should have instead recorded the diagnosis of “R septic knee

joint” as had been written on the electronic booking information;

281

b. the most recent clinical observations were confirmed as between the flags, and a

further note at the end of the Handover Printout states:

Re: Are the most recent clinical observations between the flags? Crew noted the

following: ‘Between the flags prior to leaving and during trip pulse 86’;

no “relevant medical history” of the patient was recorded as being handed over;

d. “MRSA” was recorded as an infection risk;

275

Tab 11A Supplementary Statement of RN Mulvey, at [5]

276

Tab 13F Supplementary Statement of RN Sillitoe, at [6]

277

Tab 25A Supplementary Report of RN Eunice Gribbin, at [3.3] and [4.2]

278

Tab 22O Letter from the Crown Solicitor’s Office regarding transfer, triage and handover, Annexure A, at p.8

279

Ibid

280

Tab 22E HealthShare Handover Printout

281

Tab 16A Supplementary Statement of RN Tierney, at [9A]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

e. PTS crew assessment of the condition of the patient at the end of the transfer was

“unchanged”, however a note following this states:

Re: Advise if the patient has an altered cognitive state (e.g. confusion)? Crew

noted the following: ‘delirious which became worse in the last 20 minutes’

227. RN Mulvey confirms that RN Tierney had told her that Ms Smith had become delusional

in the last twenty minutes of the journey.

282

228. RN Mulvey states that when she observed Ms Smith she “looked very unwell. She was

peripherally cold and unable to answer questions when asked, and only mumbled in

response. Her mouth was dry, her eyes were only slightly opened and she was moving

her dentures with her tongue. She did not respond to verbal commands.” and that as a

result of this, RN Mulvey immediately alerted the RN in charge and informed the Chief

Medical officer of Ms Smith’s condition, after which Ms Smith was transferred to the

resuscitation bay.

283

Transfer of Ms Smith to resuscitation bay

229. PTO Margery states that when the two nurses returned to Ms Smith on the stretcher,

the ARRH nurse (known to be RN Mulvey) said “let’s go to bed 5”,

284

and PTO Margery

started moving Ms Smith there accordingly but after a few steps the ARRH nurse said

that they should instead go straight to Resus Bay 2 (marked as Patient Bay – Resuscitation

0-014 on the map of ARRH).

285

230. RN Tierney describes in her statement that while transferring Ms Smith on a stretcher

to her designated bed, the ED nurse-in-charge (known to be RN Sillitoe) approached

and attempted but could not rouse Ms Smith and redirected RN Tierney to a bed in the

resuscitation bay at 3.30pm.

286

231. PTO Margery recalls Ms Smith was transferred to the bed in Resus Bay 2 before PTO

Margery departed with the stretcher prior to CPR commencing.

287

232. The PTS incident report records the ‘initial action taken’ as follows:

282

Tab 11 Statement of RN Mulvey, at [6]

283

Ibid, at [7]; Tab 16B on the PTO Rachel Margery states that Bed 5 is marked as “Patient Bay Acute Treatment 0-

048” on the map of ARRH at Annexure A

285

Tab 16B Statement of Rachel Margery, at [16] and [17]

286

Tab 16 Statement of RN Tierney, at [23]-[24]

287

Tab 16B Statement of Rachel Margery, at [18]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

We immediately transferred Mrs Smith off the trolley to a bed in the Resus Bay under

the care of the Emergency Nurses.

Resuscitation attempt

233. RN Tierney states that the ED nurse-in-charge commenced chest compressions after

checking for a heartbeat and requested RN Tierney to press the red emergency button,

which she did.

288

234. ARRH Progress / Clinical Notes set out a timeline of CPR commencing at 3.35pm

289

and ARRH ED Triage Notes, at 3.15pm record:

-not responding to voice or painful stimulus

-monitor connected, found pt to be in ventricular fibrillation, no carotid pulse palpated

-pads applied, shocked [with] 200J

-CPR started immediately

-MET call activated

On airway – Dr young – [Guedel] + BVM – ready to bag

TL: Dr Hawksford

Medical team from ward arrived quickly to assist

Continue on for 30 minutes [with] ALS [Advanced life support]-asystole

290

235. At 4.07pm the decision was taken to stop resuscitation. Ms Smith was declared

deceased.

291

Dr Natukokona’s involvement in Ms Smith’s treatment at ARRH

236. Dr Natukokona confirms that he had no communication or information about Ms Smith

on 1 April 2018 until he met her at 3.14pm when she arrived at ARRH and was brought

into the Resuscitation Bay.

292

237. Dr Natukokona states that he reviewed Ms Smith’s right knee at that time and states that

he found it to be normal, with no erythema, no warmth, no swelling and no obvious

drainable joint effusion”.

293

238. Dr Hawksford, who was involved in the resuscitation of Ms Smith, recalls Dr

Natukokona standing by the bed of Ms Smith during the attempted resuscitation and

holding a syringe.

294

288

Tab 16 Statement of RN Tierney, at [23]-[24]

289

Tab 20 ARRH Records, p.13

290

Tab 20 ARRH Records, p.12

291

Ibid, p.13

292

Tab 9 Statement of Dr Natukokona, at [45]

293

Ibid, at [46]

294

Tab 17A Supplementary Statement of Dr Hawksford, at [4]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

239. A/Professor Holdgate has reviewed clinical photographs of Ms Smith’s right knee, which

were taken on 6 April 2018 at the autopsy of Ms Smith, and states that those photographs

confirm the clinical impression of Dr Manning, including a large effusion in the knee

joint.

295

Subsequent events that day

240. At 6.30pm Dr Manning made the following entry into clinical notes after having been

advised of Ms Smith’s death:

Reviewed notes after contact from Constable Matt Lee-Winser of Armidale Police

– advised of Maureen Smith’s death at the Armidale emergency.

Please note results as listed above were not relayed to myself, was reviewing bloods with

RN Raymond MacLean immediately before notification.

296

241. At 11.30pm NSW Pathology telephoned blood culture results to Dr Mazen Ashour ED

ARRH informing them that both blood cultures and a midstream urine test confirmed

staphylococcus aureus.

297

242. Dr Manning states that, upon review of those records, the blood culture results detected

gram positive cocci and that:

had I known of the gram positive cocci blood culture results, at any stage, this would have

confirmed a diagnosis of sepsis, as a complication of my working diagnosis of septic

arthritis.

298

G. POST MORTEM RESULTS AND EXPERT ANALYSIS

243. The Autopsy Report concludes that:

The findings are consistent with death due to Staphylococcus aureus septicaemia due to

septic arthritis of the right knee. The corticosteroid injections performed 10 days prior to

her death are a likely source of infection. A contributing factor in the death may be the

management of this case at Glen Innes and Armidale Hospitals, specifically the delays in

transport of the deceased and the subsequent commencement of appropriate

management.

299

244. Results from testing on 31 March 2018 demonstrated MSSA

300

(which was different to

the MRSA organism colonizing Ms Smith’s ulcers chronically over earlier years)

301

and

results from testing the following day measured staphylococcus aureus at >10^8/L,

295

Tab 24C Second Supplementary Report of A/Professor Holdgate, p.5

296

Tab 19 GIDH Records

297

Tab 19A Pathology North Blood Culture Report, p.13; Tab 15 Statement of Professor Wilson, Annexure H

Specimen Audit History

298

Tab 7A Supplementary Statement of Dr Manning, at [9]-[10]

299

Tab 2 Autopsy Report, p.5 at [7]

300

Tab 19A Microbiology Report dated 3 April 2018, p.94

301

Tab 23 Expert Report of Professor Rawlinson, p.4 at [4]

INQUEST INTO THE DEATH OF MAUREEN ANNE SMITH

Summary of evidence as at 13 September 2022

Liability limited by a scheme approved under Professional Standards Legislation

which was not sensitive to Methicillin but was sensitive to Flucloxacillin, (or, according

to A/Professor Holdgate, sensitive to “standard antibiotic therapy”).

302

Professor

Rawlinson opined that there were “a number of antibiotic choices for Ms Smith at that

time”.

303

245. According to A/Professor Holdgate, it is “almost certain that the joint injections on

either 12 or 21 March were the cause of Mrs Smith’s septic arthritis and subsequent

generalised sepsis” with the more likely source being the shoulder injection on 21

March.

304

246. A/Professor Holdgate opines that there is no doubt that administration of antibiotics on

the afternoon of 31 March 2018 (and probably even on the morning of 1 April 2018)

would have increased Ms Smith’s chances of survival, however, in her view, it is

impossible to quantify that increase.

305

A/Professor Holdgate opines that without any

antibiotics, risk of death was very high; with antibiotics, the risk would have been

substantially lower but still in the order of 30%.

306

247. Professor Rawlinson opines “[i]t is uncertain what the cause of sepsis for Ms Smith was”

but that it was “likely” that the corticosteroid injections in March 2018

307

could have

contributed to Ms Smith’s acute infection.

308

248. Professor Rawlinson states “Ms Smith was at high risk of death … from an acute septic

or other inflammatory event”. He opines that it is not possible to give a definitive opinion

regarding Ms Smith’s chance of survival had she been given antibiotics to which the

MSSA was susceptible but does state that providing “appropriate” antibiotics would have

led to a better chance of survival, particularly if administered within 24 to 36 hours prior

to her demise. He states that the antibiotic likely to be administered would be broad

spectrum antibiotics such as ceftriaxone, “which would not have been as appropriate as

specific antibiotics such as flucloxacillin or clindamycin, although they would to some

extent have reduced progression of her MSSA infection.”

309

302

Tab 19A Microbiology Report dated 3 April 2018, p.94; Tab 24A Expert Report of A/Professor Holdgate, at

[1.1], [1.18], [5.1]-[5.3]; Tab 23 Expert Report of Professor Rawlinson, p.4 at [4.0(4)]

303

Tab 23 Expert Report of Professor Rawlinson, p.4 at [4.0(4)]

304

Tab 24A Expert Report of A/Professor Holdgate, at [7.2]

305

Ibid, at [8.1]

306

Ibid, p.12 at [8.3]

307

Professor Rawlinson refers to the injections “administered by Dr Diebold on 14 March 2018 and 21 March

2018”, however other material evidences the first injection to have been administered by Dr Petroff on 12

March 2018 (see paragraphs [16] and [18] of this Summary of Evidence)

308

Tab 23 Expert Report of Professor Rawlinson, p.6 at [6]

309

Ibid, at [7]