In 2002, Australian health ministers endorsed and agreed upon a list of eight adverse, preventable health events that should never occur. The list was titled ‘Sentinel Events’ and comprises of a number of adverse events that result in death or serious harm to a patient. The eight nationally agreed sentinel events are:
- Procedures involving the wrong patient or body part resulting in death or major permanent loss of function;
- Suicide of a patient in an inpatient unit;
- Retained instruments or other material after surgery requiring re-operation or further surgical procedure;
- Intravascular gas embolism resulting in death or neurological damage;
- Haemolytic blood transfusion reaction resulting from ABO incompatibility;
- Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs;
- Maternal death associated with pregnancy, birth and the puerperium; and
- Infant discharged to the wrong family.
According to the 2018 Report on Government Services released by the Australian Productivity Commission, there were 82 sentinel events reported in Australia in the financial year 2015/2016. The most common two events were suicide of a patient in an inpatient unit and retained instruments or material after surgery requiring re-operation or further surgical procedure.
We read with sadness the findings in the Coronial Inquest into the death of Phillip Ibrahim, who died on 30 October 2014 at the Prince of Wales Hospital.
On 17 October 2014, Mr Ibrahim was admitted to the Intensive Care Unit (ICU) at Concord Hospital with a diagnosis of community acquired pneumonia. A Central Venous Access Device (CVAD) was inserted into Mr Ibrahim’s right internal jugular vein, a major vein at the base of his neck. A CVAD is like a catheter however it is placed in large veins to facilitate the administration of medication and monitoring of venous pressure. There is usually more than one access point or line in a CVAD.
On 28 October 2014 at around midday, an order was made by the ICU staff specialist to remove the CVAD as Mr Ibrahim’s condition had improved. Mr Ibrahim was looked after by three nurses and two doctors between midday and 6pm on the day. Two of the CVAD lines were capped and properly closed. The third line remained connected to an intravenous fluid pump, although the fluid was not running.
Just after 6pm the CVAD was still in place. At 6.10pm, Mr Ibrahim suffered an immediate deterioration and collapse. An emergency was called. One of the nurses attending upon Mr Ibrahim noticed that the IV line had become disconnected, leaving the connector open to air. This meant that air was able to get into the device and, in turn, into Mr Ibrahim’s vein. He developed an air embolism in his brain that resulted in the disruption of oxygen to his brain. He developed severe brain damage. He was urgently transferred to the Prince of Wales Hospital for hyperbaric chamber treatment. This is treatment in a pressurised chamber which administers 100% oxygen in an attempt to reduce the size of the air embolism. Tragically, the hyperbaric treatment did not result in any improvement in Mr Ibrahim’s condition and he passed away on 30 October 2014.
The nursing staff acknowledged that the longer a CVAD remains in place, the longer the patient is exposed to the risk of an air embolism. The Coroner found that for reasons unknown, the nursing staff did not prioritise removal of the CVAD. In addition, the junior ICU registrar had an opportunity to intervene and direct the removal of the CVAD but did not take up that opportunity.
The Coroner made a number of findings of factors that contributed to Mr Ibrahim’s death. Those factors included that there was no policy in place which stipulated timeframes of removal of CVAD lines and there was a lack of credentialing (training) of nursing staff in the removal of the CVAD.
Crucially, the Coroner said: “That an air embolism was a rare event and had not occurred at Concord Hospital prior to Phillip’s death in 2014 in no way reduced the need for staff to properly recognise and act to mitigate the risk of such an event.”
The Hospital accepted that an air embolism is an avoidable and preventable event. By the time the Inquest was heard in August 2018, it had implemented a number of measures to avoid such an event in the future. Those measures included:
- Implementation of a ‘best practice benchmark’ of removal of CVADs within four hours of the order.
- Daily assessment of patients and ongoing evaluation of the need for insertion of CVADs, continued use and need for removal.
- A commencement of a shift checklist in the ICU to ensure staff were reminded of the need for removal of invasive lines as soon as possible.
- Positive actions were taken to increase credentialing of staff within the Unit. It is now above 90% a marked increase to the ratio in 2014.
- If a delay in removal was experienced due to lack of accredited staff, the ICU Clinical Nurse Educator or Clinical Nurse Consultant would assist to remove the device.
- To ensure clear documentation on a patient’s medical record for CVAD removal, a specific labelled sticker was designed and implemented. This provided clear directions for removal and the four hour benchmark. Notation of the time of the order and the time of removal was required to facilitate auditing of CVAD removal timeframes.
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Mr Ibrahim’s case is a sad example of an avoidable event with a tragic outcome. In addition to participating in the Inquest, Concord Hospital would have performed an internal investigation and produced a Root Cause Analysis report. For further information on NSW Health incident management policies, read our blog.
Adverse events happen regularly in healthcare settings on a daily basis in Australia. Not all adverse events and substandard treatment amounts to medical negligence.
At Turner Freeman, we have lawyers who specialise in medical negligence claims who are able to advise you regarding your entitlements in this complex area of law. If you or someone you know has suffered as a result of medical negligence, we encourage you to call us on 13 43 63 to speak with one of our medical law experts.