Coroner calls for change at nursing home after death

A QUEENSLAND coroner has recommended a Toowoomba nursing home change its internal documenting protocols after the unexpected death of a man in 2013.

Albert Eric Bruce Biffin was 86 and living in Jacaranda Place at Blue Care when, on February 24, 2013, he became unwell after a minor hernia procedure.

A coronial inquest sought to establish the cause of death and determine whether it was "health-care related".

The inquest heard Mr Biffin's condition deteriorated slowly after the hernia procedure, a fact noted by Blue Care nursing staff who faxed a report to his regular GP, Dr John Lambie, on February 24.

Dr Lambie examined Mr Biffin the following day, noting he was constipated but "excluded the possibility that Mr Biffin was suffering from an obstructed bowel", and reduced the hernia during his examination.

Ordering nursing staff to administer medication, Dr Lambie verbally told staff to alert him if Mr Biffin's condition deteriorated.

"Subsequently there was no record of complaint of pain or vomiting but Mr Biffin's overall condition deteriorated until his final collapse immediately following vomiting at about 23:15 (11.15pm) on 26 February, 2013," Brisbane coroner Christine Clements found.

Ms Clements found Mr Biffin died from cardiac arrest, the causes of which were "complications of an incarcerated umbilical hernia", in the early hours of February 27, 2013.

"The medical cause of death was complications of an incarcerated umbilical hernia," Ms Clements found.

"Cardiac arrest was triggered by an electrolyte imbalance and sepsis which developed as a result of a necrotic and poorly functioning small bowl."

She recommended Blue Care require personal carers and nursing assistants to "enter any variation in a resident's condition in the progress notes", a factor which during the inquest was found to have been inadequate.

"The note should document to whom it was escalated and the enrolled nurse or registered nurse record in the progress notes the assessment and response," Ms Clements recommended.

"The record must be sufficient to inform nursing staff from one shift to another what action the doctor requires and in what circumstances the doctor or emergency services should be contacted."

She also recommended, "Blue Care further consider further training of personal carers and assistants in nursing authorising them to make entries in the medical records where appropriate.

"This recommendation recognises it is people in these roles who often have greatest continuity of contact with the resident and therefore the greatest appreciation of any change in the wellbeing of a resident in a nursing-care facility."