Gold Coast University Hospital ED deaths, disarray exposed in leaked documents

Queensland’s busiest emergency department, which can be packed with up to 170 patients at a time, has been exposed as a hotbed of death and disarray.

Gold Coast University Hospital

The tragic deaths of a man found unresponsive in a hospital toilet and another who died of an agonising infection have exposed alarming clinical failings at the state’s busiest emergency department.

Leaked documents from reviews into the deaths at Gold Coast University Hospital reveal failings in treating common but deadly conditions such as chest pain and sepsis.

The review team’s reports were emailed to hospital staff from Gold Coast Health last week. One probe looked into a death of a patient with chest pain in the ED’s toilet.

The investigators highlighted that the ED did not have a published procedure for the management of chest pain.

In the second human error and patient safety review, the team looked into the death of a patient who did not survive a serious infection. The report flagged a delay in identifying sepsis and reduced awareness of the need to treat the condition urgently.

Other issues identified in the report were that overwhelmed medics at the GCUH struggled to keep up with demand, there were long delays in care in spite of vital signs pointing to a need for urgency and a seriously clogged system.

At its busiest the hospital ED can be packed with as many as 170 patients at once.

In the first case a 75-year-old man arrived at the ED after suffering chest pain for three days. The department was very busy and nursing staff were attending high-dependency areas.

“This created a patient safety risk for patients in the waiting room waiting for treatment in the ED, in particular higher-risk category-two patients”, the report found.

The patient went to the toilet where he was found unresponsive.

A code blue was activated but he was unable to be resuscitated.

The second probe was into the death of a 74-year-old who was sent to the ED by his general practitioner for a review of a perianal abscess.

He was in great pain.

Nurses documented that his vital signs were not normal and pathology showed a possible infection.

Gold Coast University Hospital emergency department

Three hours later he was placed on the sepsis pathway protocol.

Staff were concerned and flagged that he needed a doctor and this did not happen for five hours as the ED was packed.

He was assessed the next morning and sent to ICU.

The patient died after a 24-day admission.

“We are committed to delivering high quality and safe healthcare to all patients in our hospitals,” a Gold Coast Health spokesman said.

“As a learning organisation, clinical reviews are a key mechanism for the continuous improvement of patient care.

“Gold Coast University Hospital is one of the busiest emergency departments in the country and we recognise the challenges our medical workforce face in the hospital environment.

“These are sad events for all involved and our thoughts remain with the patients’ families.”

Open-disclosure discussions have been offered to families.

In response to issues raised in the case of the patient with chest pains who died in toilets, the health service said he was properly assessed and triaged.

“Gold Coast Health follows state wide management pathways for chest pain. It was recommended that this pathway could be improved by documenting tailored pathways for Gold Coast Health emergency staff. All adult patients with chest pain are triaged as category Two unless they are in cardiac arrest,” he said.

“Clinical teams closely monitor demand and well-established strategies help optimise inpatient bed availability,” the spokesman said.

Referring to the patient presenting with serious infection the spokesman said that he was under the care of medical teams for a significant period.

“Diagnosing cases of sepsis coupled with a very rare condition is complex and often requires ongoing clinical investigations to determine appropriate treatment, which of course takes time,” he said.

“Once sepsis is suspected, the appropriate tests are ordered.”

Originally published as Gold Coast University Hospital ED deaths, disarray exposed in leaked documents