Coroner Parkinson determined that the discharge timing was reasonable but commented on the HITH program, noting that its setting means a lower level of attendant care and observation, and places much responsibility on relatives. She found that, in Andrew’s case, the process was fraught with mixed messages and uncertainty because of a breakdown in communication between the hospital and family, and the hospital staff assessing Andrew by telephone being unfamiliar with his case. “Delegation of responsibility to a lay person to make an assessment of a worsening condition…is not ideal management.”
The Coroner could not conclude whether earlier intervention or hospitalisation would have prevented Andrew’s death but made a number of recommendations to improve the program.
The recommendations focused on communication issues and an escalation procedure.