Tragic case illustrates risks of informal consultations and unstructured handover 

Informal, corridor or other casual situations where clinical care need are addressed should be held to the same standards as any other patient interaction. Thorough and contemporaneous documentation, and a structured handover is essential to ensure good communication between healthcare practitioners. Except in emergencies, you should not provide care to family members, close friends, and those you work with. In these situations, you may lack objectivity and patient care is likely to be fragmented.

Six-year-old SK had been home from school with a mild flu for several days. His parents, both registered nurses, were separated. Over the course of several days as his condition progressively worsened, his parents separately took him three times to the regional hospital where they both worked.

He was sent home from the hospital on two occasions. On the first occasion SK was informally seen by Dr C in the emergency department and provisionally diagnosed with a viral infection.  On the second occasion, SK was initially seen and assessed by Dr R who ordered a chest x-ray.  The patient was then sent home the same day by Dr C following changeover of shifts and after reviewing the x-ray. 

His mother then took him to the medical centre where the GP suspected scarlet fever and insisted he must be admitted to hospital. The consultant paediatrician, Dr I, admitted SK to the high dependency unit with a provisional diagnosis of scarlet fever and possible chest infection. He did not recognise that SK was already showing signs of septic shock. That night SK became progressively more unwell and feverish. Eventually he stopped breathing and could not be revived.

Pathology reports concluded the cause of SK’s death was bacterial sepsis arising from bacterial pneumonia secondary to influenza.

The coroner found the ultimate cause of death was complications from a natural illness but the inquest identified several issues and missed opportunities in SK’s treatment.

Informal consultation of a colleague's family member 

SK’s first examination was an informal ‘corridor consultation’. SK’s father worked in the emergency department and took SK with him on a social visit. Other staff noticed a rash on SK’s body and insisted a doctor should look at him.

Dr C, the experienced locum on duty, took a history from SK’s father and performed a thorough examination. At this stage SK had no temperature or signs of infection and appeared alert and happy. Dr C considered SK’s symptoms presented like scarlet fever but in the absence of other clear signs, she diagnosed a viral illness, with a differential diagnosis of scarlet fever or tonsillitis. She provided an ‘as required’ prescription for penicillin. SK went home with his father.

SK had not been formally triaged, and no clinical record was created. Dr C did not make notes of the consultation.

At the inquest into SK’s death, it was recognised that Dr C had been placed in a difficult position. She had only recently started working in the department and had felt pressured to see SK. At the time, informal consultations were not uncommon.

The coroner accepted that Dr C had conducted a thorough examination and formed an appropriate diagnosis.

Documentation 

Experts were critical of the poor note-taking throughout SK’s treatment.  They were also critical of failures to read other clinicians’ notes.  This meant that doctors assuming care were unable to benefit from other colleagues’ examinations or understand their care or treatment plans.

The coroner was critical of Dr C’s lack of documentation during SK’s initial assessment. It meant that there was no information about assessment when his mother brought SK back to the emergency department for the second time.

Additionally, the coroner criticised the lack of documentation of any handover discussion between Dr R and Dr C when Dr R was leaving the hospital.  Neither Dr R nor Dr C documented any discussion, nor did Dr C document her examination of the x-ray.

Communication

The coroner highlighted several communication failures particularly relating to the handover between Dr R and Dr C on SK’s second presentation.   

Dr R claimed he intended for Dr C to review the films and reassess as to whether SK required antibiotics or hospitalisation. Dr C understood she only needed to check the x-ray and discharge SK if nothing significant was seen. She did not examine SK or review Dr R’s notes, so was not aware SK was now experiencing fever and cough. She saw no signs of pneumonia and discharged SK home with his mother.

At the time the hospital was trialling the handover with the ISoBAR system. Neither Dr R nor Dr C were trained about or proficient in using this model.

The coroner concluded that had the ISoBAR system had been used, it is unlikely there would have been a misunderstanding between Dr R and Dr C.

On that occasion, SK was seen by Dr R. He also suspected a viral illness but arranged a chest x-ray to rule out pneumonia. The x-ray was completed later that afternoon as Dr R was leaving work, so he handed over to Dr C.

The coroner concluded that SK’s cause of death was complications from pneumonia, including scarlet fever and bacterial sepsis.

He was critical of systemic and process issues leading to missed opportunities to diagnose and treat SK’s condition.

Following SK’s death, the area health service implemented a mandatory triage process before any patient could be seen in the emergency department.

It also implemented systems for reviewing clinical records to check for completeness and accuracy, and for colour-coding observation charts for clinically deteriorating paediatric patients.

Wherever possible, avoid treating family members, close friends or those you work with. Such consultations can lead to discontinuity of care.

If you do need to treat someone close to you, always keep careful records of any such consultation and treatment that you provide.

Whenever providing care it is important to make a contemporaneous record of the details about the patient’s health that would allow someone else to take over care of the patient without having to speak to you.

Ensure you record clinical observations, medications or treatments provided, as well as your reasoning, rationale for reaching a diagnosis and differentials you excluded.

Breakdowns in handover or communication between clinical care teams can lead to diagnostic errors. If you are accepting handover of care, make sure you have enough information to assume care for the patient. Structured handover using ISoBAR tools can help reduce misunderstandings.

Avant factsheet - Treating family members friends or staff

Avant eLearning – Medical records: Chapter one – documentation

Avant factsheet - diagnostic error 

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