Patient mortality and the neglect of vital signs' assessment: An audit of a national coronial database.

Background: Vital signs assessment is critical for patient surveillance and safety. Research has found, however, that this assessment is often neglected in clinical practice. The reasons for this are unclear as few studies have explored this issue. Those studies that have are small, single site studies and found that culture and poor understanding are contributing factors.

Aim: The aim was to explore the link between the clinical neglect of vital signs assessment and patient mortality and provide a better understanding of factors influencing vital signs assessment in the context of acute patient care. Coroners' reports represent an untapped source of information regarding shortfalls in vital signs assessment. Using a framework analysis, an audit was conducted of the Australian National Coronial Information System for cases where vital signs' assessment was mentioned in coronial reports.

Results: Fifty-eight cases met the eligibility criteria, with deceased patients aged from 7 days to 93 years. Key themes related to absence of reassessment of vital signs, inappropriate delegation, passing responsibility to another staff member and not following policy.

Conclusions: The findings reflect a combination of individual and institutional failings and suggest that vital signs assessment was not considered a priority aspect of care.

Relevance to clinical practice: Vital signs assessment must be considered an essential aspect of clinical care in all patients. This important aspect of care should be emphasized across all domains of patient care.