Territory Stories

Coroners Act Response to the Coronial Findings in the matter of Ms Irene Magriplis dated 21 September 2017



Coroners Act Response to the Coronial Findings in the matter of Ms Irene Magriplis dated 21 September 2017

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Tabled paper 426


Tabled papers for 13th Assembly 2016 - 2020; Tabled papers; ParliamentNT






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42. The HDU was an area on the ward with three beds that were monitored by one nurse. The nurse was a Registered Nurse but had no special training in intensive care procedures and no training for working in the HDU. 43. The family stayed in the HDU area while their mother was settled. She continued to complain of feeling nauseous, having extreme abdominal pain, being thirsty and burning inside. She was given Maxolon for the nausea and vomited. 44. The family noted the abdominal drain. There was light coloured, blood like fluid at the top of the drain and a thick discharge beneath. They spoke to the nurse about it. The nurse then spoke to a supervisor. However they were not given a,n explanation as to whether that was significant or not. 45. The family were told they couldn't stay overnight. Throughout the night Mrs Magriplis was kept on oxygen therapy of two .to three litres per minute. Her respiratory rate was fairly constant until midnight. After that it became more erratic, dropping to 15 breaths a minute at 2.00am and then rising to 27 breaths per minute at 4. OOam. 46. The observations were recorded on an "Adult General Observation Chart'" (Chart). The Chart was of the "track and trigger" variety. It had a white area indicating normal observations bounded first by a yellow zone and then a red zone after that. 47. The instructions to the Chart stated that the yellow zone indicated the need for a clinical review. The following was in capitals, "IF A PATIENT HAS ONE (1) OR MORE CLINICAL REVIEW CRITERIA PRESENT, YOU MUST CONSULT PROMPTLY WITH THE NURSE IN CHARGE AND ASSESS WHETHER A CLINICAL REVIEW IS NEEDED ... " 48. One of the actions then required was the recording of repeat observations within 30 minutes.

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