//Investigation report Royal Brisbane and Women’s Hospital October 2016

Investigation report Royal Brisbane and Women’s Hospital October 2016

14 October 2016

The following matter was referred to the Health Ombudsman as part of the transitional process from the Health Quality and Complaints Commission (HQCC) following legislative changes on 1 July 2014. The complaint was made by the mother of a patient regarding the health service her son received from the Rockhampton Hospital and Royal Brisbane and Women’s Hospital (RBWH) from August to December 2013.

The complaint

The complainant raised the following concerns about the treatment provided to her son and identified the following issues for investigation:

  • The delay in diagnosing her son’s condition and a further delay to initiate treatment contributed to the poor outcome.
  • Poor communication between her son’s treating medical teams contributed to poor coordination in care and a poor outcome.
  • Fragmented and poor communication between RBWH staff and her and her family.
  • Delays in recognising her son’s seizure activity and delay in providing treatment.

The complaint regarding Rockhampton Hospital was not progressed as the initial assessment did not identify any concerns with the manner in which Rockhampton Hospital managed the patient. The complaint regarding RBWH was progressed to investigation and was transferred from the HQCC to my office on 1 July 2014.

The issues

A review of the original written complaint and initial information provided from HQCC identified the following issues for investigation.

Issue one—The alleged delay in diagnosing and initiating treatment contributed to the poor outcome for the patient:

  • The failure to consider an alternative diagnosis to that of the patient’s known history, despite progressive neurological deterioration.
  • Significant delay in further investigation and treatment, including insertion of EVD, despite the patient becoming comatose.

Issue two—The alleged poor communication and coordination of care between treating medical teams contributed to the poor outcome for the patient:

  • Failure to identify and manage a critical clinical deterioration of the patient in line with RBWH medical emergency call criteria protocols.
  • Inconsistent and brief documentation in recording observations on the patient’s different charts failed to appropriately record the seriousness of his condition and progressive neurological deterioration.
  • Failure to communicate critical information to all members of the treating team.
  • Lack of protocol and policy at RBWH to inform senior medical officers and treating consultant of clinical deterioration or concerns.
  • Family being provided limited or conflicting information causing confusion and frustration.

Issue three—The alleged delays in recognising and providing treatment for the patient’s seizure activity:

  • Failure to action concerns raised by the family regarding further deterioration and seizure-like activity between 20 September 2013 and 23 September 2013 following insertion of a shunt on
    19 September 2013.

Evidence obtained

The following information was obtained from the RBWH by the HQCC as part of its initial investigation:

  • a submission in response to the allegations
  • the patient’s medical records
  • the root cause analysis (RCA) document.

Following a review of the documentation provided by the HQCC, the Office of the Health Ombudsman requested and received the following additional documentation:

  • additional medical records for the patient relating to his admission to Rockhampton Hospital on 23 August 2013 up to his discharge from RBWH in December 2013
  • statements from practitioners involved at critical junctures in the patient’s treatment
  • additional information from the complainant in relation to her concerns and the events that took place at RBWH
  • an update from RBWH on the implementation of the RCA recommendations and lessons learned
  • independent clinical advice from a registered medical practitioner specialising in neurosurgery.


The Health Ombudsman made the following findings in relation to the identified issues:

  • Issue 1—The allegation that the delay in diagnosis and treatment of the brain abscess contributed to the poor outcome is substantiated.
  • Issue 2—The allegation that the poor communication and coordination of care between the treating medical teams contributed to the poor outcome for the patient is substantiated.
  • Issue 3—While there were deficiencies in the communication with the patient’s family, when recorded, appropriate actions were taken to treat the seizure-like activity.


After reviewing and analysing the evidence, the Health Ombudsman determined that the actions taken by RBWH to address the poor outcome for the patient appear to deal adequately with the key issues and to mitigate future risk.

To satisfy the Health Ombudsman that the health and safety of the public is protected in the future, and to determine whether the lessons learned from this incident and actions undertaken have effectively mitigated the risks, Metro North HHS has agreed to the following recommendations.

Recommendation 1—Metro North HHS undertake an evaluation to determine the effectiveness of:

  • the implementation of the revised urgent clinical review procedure across the Metro North HHS
  • the changes made to the revised urgent clinical review procedure in improving medical and nursing/midwifery response management of the deteriorating patient at the RBWH.

Recommendation 2—Metro North HHS develop and implement an action plan to increase staff and consumer awareness of Ryan’s Rule throughout the RBWH.

The Health Ombudsman determined that no further action will be taken in relation to the matter and the investigation is now closed in accordance with section 44(1)(a)(iv) of the Health Ombudsman Act 2013.

Read the report