Download Rapid investication for gastrointestinal

From Death We Learn 2009
Rapid investigation for gastrointestinal
haemorrhage
Office of Safety and Quality in Healthcare
Reference: Fox Inquest
February 2009
Office of Safety and Quality in Healthcare
The Case
Background
• A man in his 60’s presented to a tertiary hospital emergency
department at night
• following an episode of syncope due to a gastrointestinal bleed.
• in shock
• mixed altered and fresh blood on rectal examination.
– symptoms consistent with both upper & lower gastrointestinal
bleeding having
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Office of Safety and Quality in Healthcare
The Case
Management
The patient was:
• resuscitated & stabilised with intravenous packed cells &
intravenous fluids.
• referred to surgical and medical (gastrointestinal) units
However:
• investigation was withheld until daylight hours.
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Office of Safety and Quality in Healthcare
The Case
Outcome: in the morning & prior to investigation
• The patient became hypotensive due to haemorrhagic shock.
• Urgent endoscopy could not be arranged
• The patient remained in the Emergency Department.
• The patient died from peptic ulceration with secondary
gastrointestinal haemorrhage despite aggressive attempts at
resuscitation.
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Office of Safety and Quality in Healthcare
The Inquest
A coronial inquest revealed:
• The patient had a recent history of abdominal pain diagnosed
as constipation in a general practice setting as well as a
peripheral hospital emergency department.
• The patient did not report self medication with aspirin and
ibuprofen when asked about his usual medications.
• That urgent endoscopy was indicated after the initial
resuscitation but had not been requested by the medical or
surgical teams.
• There was uncertainty about which inpatient service
(medical or surgical) was managing the patient due to
clinical uncertainty about the site of haemorrhage.
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Office of Safety and Quality in Healthcare
The inquest
A coronial inquest revealed:
• That when endoscopy was requested, it was not immediately
available
• Difficulty accessing emergency surgical and
gastroenterology services within office hours once day
commitments are commenced if dedicated cover for
such events is not pre-arranged.
• Inconsistency between medical and nursing documentation
• medical documentation could be missing
• The patient’s death occurred by the way of natural causes
but may have been preventable with timely and appropriate
investigation and treatment.
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Office of Safety and Quality in Healthcare
Key Question
Can this still happen?
• Since the patient’s death, the hospital had revised its
gastrointestinal haemorrhage protocol & formed an agreement with
surgeons and gastroenterologist to improve emergency procedures
cover.
• The Deputy State Coroner recommended that the proposed plans
for a High Dependency Gastrointestinal Unit with safer endoscopy
suites with an extended Intensive Care Unit be progressed
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Office of Safety and Quality in Healthcare
Key messages
Gastrointestinal haemorrhage can be a rapidly
progressing life threatening condition despite
stabilization after initial resuscitation.
Clinically determining whether a gastrointestinal
bleed is upper or lower can be difficult.
There is a need for clear pathways for the emergency
management & referral of patients with
gastrointestinal haemorrhage.
Where emergency services are provided, clear lines
of responsibility for 24 hour coverage need to be
established.
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