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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"Accurate input and output recording. Ability to recognise and respond to fluid imbalance." 73. The nurses on those three shifts appeared unable to properly and accurately wr.ite up the Fluid Balance Sheet. For the entries in the Fluid Balance Sheet on 27 May 2015 there were no progressive totals for either the intake or output. If the object of the sheet is to determine the fluid 'balance' then that creates a significant issue. 74. Various entries were clearly in the wrong columns and on two occasions figures were written and then crossed out, but no further entries made. On 28 May 2015 there were no outputs noted for the drain excepting for the entry at 7 .OOam where it stated "400 - change drain", 75. The nurse told me that s~he wrote the progressive totals for that day including those after midnight (those before she came onto her shift). Those totals take into account the 400 millilitres on the change of the drain, but no other amounts from the drain. Not even the 70 millilitres that Mr Treacy saw just before 8.00am. No hourly amounts were recorded on the Sheet after midnight other than the 400ml. 76. I also heard from Dr Charles Pain that the HDU was unlikely to comply with the College of Intensive Care Medicine of Australia and New Zealand Guideline. To comply, a High Dependency Unit must be geographically part of the intensive care complex of the hospital and be operationally linked to the ICU. 10 Failure to Recognise Fluid Draining from Abdomen 77. Mr Treacy told me that had he been aware there had been 400 millilitres in the drain overnight he would have taken Mrs Magriplis back to the theatre for reoperation immediately. If he had done so, the reoperation would have occurred 18 hours earlier. The failure to recognise that the drain had been changed is therefore of crucial importance. 10 Pain para 56
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