Please attribute the following to Health Service Chief Executive Hannah Bloch
We continue to hold Mr Irving's family in our thoughts and offer our deepest condolences during this incredibly difficult time.
Today our staff met with the Irving family to discuss the final review of the events surrounding Mr Irving's care.
The review confirmed that earlier diagnosis or treatment may not have changed the clinical outcome but did identify areas where we could have provided a more compassionate experience for Mr Irving and his family.
We assured the family that this is an important lesson we are committed to learning from and outlined the actions that have, and will, be taken.
These include reviewing the need to ensure better pain management for patients on the ramp, more efficient social worker support for families facing similar situations and considering whether video footage may assist with future clinical incident reviews.
These improvements build upon the recent addition of nurse and medical commanders in our ED.
Additionally, Mr. Irving's case will be used as a case study for triage training, further enhancing our ability to provide timely and compassionate care.
BACKGROUND
West Moreton Health has finalised its review into the death of Wayne Irving in the Ipswich Hospital Emergency Department on 17 November 2023. This review was undertaken by internal and external senior clinicians and representatives from the Queensland Ambulance Service (QAS).
The recommendations have been shared with Mr Irving’s family and a follow-up meeting with the family has been held to discuss the review.
The review identified several adverse factors in Mr Irving’s care:
- Demand pressures on Ipswich Hospital and particularly the Emergency Department.
- Lack of dedicated nursing and medical staff to oversee patients on the ‘ramp’*.
- Misinterpretation of the procedure for strong pain relief medication for patients on the ‘ramp’
- The patient’s ultimate diagnosis may not have been a consideration at triage.
- A social worker was unavailable onsite in the Emergency Department after hours to support the patient’s family immediately after Mr Irving’s death.
*Note, the ambulance ‘ramp’ is located within the Ipswich Hospital ED and does not refer to the ambulance driveway as has been reported in the media.
The report made the following recommendations:
- Introduce medical and nurse commander roles to better oversee monitoring and escalation of patients on the ramp.
- Update the procedure on opiate use to specifically include patients on the ‘ramp’.
- Include a case study based on the circumstances of Mr Irving’s death in triage training.
- Review social work resourcing after hours in ED.
- Consider whether video footage may assist with future clinical incident reviews.
UPDATE 19 July 2024
All recommendations [DOCX 461.71 KB] were implemented by the due date of 31 July 2024.