Coroners Act Response to the Coronial Findings in the matter of Ms Irene Magriplis dated 21 September 2017
Tabled paper 426
Tabled papers for 13th Assembly 2016 - 2020; Tabled papers; ParliamentNT
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burning inside. The anaesthetist, Dr Harbison came by on his tnorning rounds. He said everything was fine. 57. At 7.30am the nurse took the first set of observations for that shift. She found that the blood pressure of Mrs Magriplis had fallen from 120/60 at 6. OOam to 72/3 8 at 7.3 Oam. That was deep into the red zone on the chart. Oxygen saturations were in the yellow zone at 93% despite being on 3 litres of oxygen per minute, her heart rate had risen sharply from 80 beats per minute to 100 beats per minute (albeit still in the normal zone). The nurse did not record other observations on the chart. 58. I heard evidence from Dr Charles Pain, the Executive Director of Medical Services at the Royal DarwiJ:l Hospital, that those observations at the Royal Darwin Hospital require a Code Blue to be called. A Code Blue is the highest emergency escalation for a patient. 59. The instructions to the Chart state that the rd zone is the "Rapid Re-sponse" zone. The Instructions for that zone advise (in capitals): "IF A PATIEN-T HAS ONE (1) RAPID RESPONSE CRITERION PRESENT, CALL FOR A RAPID RESPONSE ... " 60. The further instructions state at point 4, "Repeat observations every 5 minutes until the team arrives'". 61. What that means seems clear on a reading of it. However it became a point of some confusion at the inquest. The General Manager of the Darwin Private Hospital, Dr Joanne Seiler, gave two different versions. She filed a statutory declaration on 3 March 2017 explaining what it meant: "The system at DPH requires that where a patient exhibits one ( 1) or more of the base clinical review criteria, protocol for the initiation of a 'clinical review' must be initiated. This requires contact and reporting to the patients VMO. More serious indicators are identified as 'rapid response' criteria. If this is indicated a 'Rapid Response I. II
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