From Death We Learn 2009 Intoxicated Head Injury in a Regional Hospital Office of Safety and Quality in Healthcare Reference: Kidner Inquest July 2008

Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The Case Background A man in his 40s presented to a regional hospital Emergency Department Following a series of closed head injuries over the previous 36 hours Intoxicated with alcohol On one occasion he fell from a bar stool after which he was observed to be bleeding from the ear.

Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The Case Management In hospital he was intoxicated and aggressive, and could not be managed with available resources. He was advised to stay for observation but he refused Head injury advice sheets were provided and he was discharged accompanied by a friend.

Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The Case Outcome The man and his friend returned to a social event where he displayed erratic behaviour then fell asleep on a trampoline in full view of the party. The following morning he was unrousable, then later found deceased. Post mortem examination revealed: –a fractured base of skull –significant alcohol intoxication –fatal head injuries.

Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The Inquest Deputy State Coroner noted: Deceased had a very high tolerance to alcohol & was known for his erratic behaviour. Deceased had a series of alcohol related closed head injuries within the 36 hours prior to presentation. Death rose by way of accident BUT THAT…

Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The Inquest Deputy State Coroner noted: Hospital care, although understandable, was not optimal: There were indications for: admission & observation urgent CT scanning This was not possible because: Deceased’s behaviour could not be controlled Patient did not remain in the hospital for observation Hospital conditions did not allow the provision of proper medical care. There was no capacity at the hospital to restrain or sedate him The hospital had no CT scanner

Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare The Inquest The Deputy State Coroner made the following recommendations: (after benchmarking against towns of similar size) The hospital should be funded for a CT scan service. The hospital should be adequately funded to provide appropriate care to patients in the developing region where it is situated. The issue of inadequate security for staff and patients be addressed immediately. Head Injury criteria sheets are posted in the Emergency Department so they are obvious to patients as well as staff in stressful circumstances.

Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together ◦ Lead ◦ Transform ◦ Achieve ◦ Together Office of Safety and Quality in Healthcare Key messages  The management of patients with head injuries who are intoxicated is challenging.  A period of observation and an assessment of competence should guide decisions about discharge.  Physical restraint and sedation may be needed to manage patients appropriately.  Reasonable access to early CT scanning is the standard for all patients with significant head injury.  Guidelines for the management of head injured patients and the indications for CT scanning are available.