In the report of the Inquest into the death of Roy Jacobs the coroner identified that “Failure to recognise and respond to clinical deterioration and non-compliance with early warning and response
tools is a recognised issue across the health sector, public and private” (Coroners Court of Queensland, 2017).
The case indicates several missed opportunities for effective communication, documentation, collaborative care and escalation of care where the patient’s outcome may have been different.
The Coroner’s Report shows that Mr Jacobs’ vital signs were not taken as frequently (p18 & p35) as required for a patient scoring a 6 and above on the Queensland Adults Deterioration Detection System (QADDS).
The report shows how nursing staff on that shift failed to inform the doctor of Mr Jacobs consistently high QADDs scores, neglected to increase frequency of observations, did not request a medical review and did not advocate for retrieval to the nearest tertiary facility (p30).
Throughout the Inquest, ineffective communication was evident on many occasions from the registered nurse towards peers and other health professionals. An example of this is detailed in the Inquest on page 21, where the registered nurse failed to communicate effectively to the on-call medical officer that the patient, Mr Jacobs, required review due to his elevated Q-ADDS score of seven (Queensland Courts, 2017).