QUEENSLAND CORONER FINDS FAILURE BY A DOCTOR TO HAVE HIS PHONE CHARGED, OR TO ADVISE THE HOSPITAL OF AN ALTERNATIVE TELEPHONE NUMBER, TO BE “INEXCUSABLE” AFTER WOMAN DIES AT OAKEY HOSPITAL

Published 08 Oct 2015

Mrs Verris Dawn Wright was aged 86 years at the time of her admission to Oakey Hospital on 24 December 2013, with symptoms of abdominal pain and burning feeling when urinating.

Upon admission, she was assessed and differential diagnoses of a urinary tract infection or kidney stones were made. She was treated with pain relieving mediation (analgesics) and antibiotics, and, after several hours, discharged home into the care of her family, after reporting an improvement in her condition.

On 26 December 2013 (Boxing Day), prior to 0845 hours, Ms Wright represented to the same hospital with a history of vomiting and with severe abdominal pain and urinary incontinence. She was assessed by a nurse at the hospital’s Emergency Department, provided with blankets, heatpacks, oxygen through oxygen prongs, and was triaged to see a doctor within a 30 minute period. Despite this, she remained in the Emergency Department for the remainder of the morning under the care of the nursing stuff, and received no active treatment, and was not consulted by a doctor.

By about mid-day, Ms Wright’s condition had significantly deteriorated, her blood was tested, which confirmed the presence of an infection. Palliative treatment commenced shortly after, with Mr Wright passing away at 1235 hours, approximately 4 hours after her presentation to the Emergency Department.

An autopsy, later, confirmed, no evidence of urinary tract infection, and the cause of death as septic shock due to bowel obstruction, which caused ischaemic bowel. This was consistent with Ms Wright exhibiting “red flag” symptoms, at the time of her presentation of 26 December 2013, prior to 0845 hours, to the Emergency Department of the hospital, which were probably present, at an early stage, at the time of her presentation on 24 December 2013. These “red flag” symptoms consisted of, inter alia:

  1. Low temperature of 33.5 degree (normal being 37 degrees);
  2. Tachycardia (an abnormally rapid heart rate) of 99 beats per minute towards the higher end of the normal range of (60 to 100 beats per minute);
  3. Blood oxygen saturation of 92% but noted to drop to 87% at one point (normal being 95 to 100%); and
  4. Blood pressure measurement of 111/73 (indicative of hypotension, with normal being more than 120 over 80 and less than 140 over 90).

This matter came before the Queensland Coroner’s Court on 28 August 2015.

Sadly, Ms Wright was not the only patient to succumb to her death at the hands of same Health Service. In this regard, some seven months later, Ms Jasmyn Louise Carter, a 17 year old women, died in similar circumstances at the Warwick Hospital, being another facility under the care, control and management of Darling Downs Hospital and Health Service, and, although, the circumstances surrounding Ms Carter’s death were also the subject of this inquest, this paper only focuses on the failures that occurred at Oakey Hospital on the morning of 26 December 2015 in connection with provision of treatment to Ms Wright.

Chronology of relevant events and findings by the coroner

During the course of the Inquest, Deputy State Coroner John Lock found, inter alia, that:

  1. Following the initial assessment at around 0845 hours on 26 December 2015 RN Delaney of the Hospital, contacted Dr Byrne on the assumption that he was the rostered on-call doctor, however, was advised that it was Dr Hall who was the on-call doctor. However, Dr Byrne advised that he was happy to assist if necessary.
  2. RN Delaney then telephoned Dr Hall on the mobile number provided by Dr Byrne, but did not receive an answer and left a telephone message.
  3. At 0930 hours, Dr Hall telephoned the hospital, however, it was not in response to the message left on his phone by RN Delaney. His telephone call was received by RN Honan. RN Honan, asserted during the Inquest, which was denied by Dr Hall that, on that occasion he had also advised her that he would be at the Hospital in 30 minutes. RN Honan assumed that Dr Hall was already in contact with RN Delaney, accordingly, nothing else was mentioned, despite his enquiries as to whether he should be aware of anything else.
  4. At 0935 hours RN Delaney performed another examination on Ms Wright, and found an improvement in oxygen saturation and blood pressure, but a persistent low temperature of 33.6 degrees.
  5. At 1030 hours, RN Delaney, again, telephoned, Dr Hall. The call went straight to message bank and she did not leave another message.
  6. At 1040 hours, Ms Wright’s observations were unchanged from the previous examination, but were not recorded on the Rural Emergency Flow Sheet.
  7. At 1120 hours, RN Delaney notes some confusion in Ms Wright and at 1125 to 1130 hours that she was unable to focus or respond to questions when asked.
  8. At 1140 hours, RN Honan noted that Ms Wright had deteriorated, and RN Delaney, again, telephoned Dr Hall and left an urgent message. Dr Hall did not received this message, as it was sent to his mobile, which was out of charge.
  9. At 1158 hours, DON Boyd used his mobile to telephone Dr Hall on his private number. On that occasion, Dr Hall advised that he was unaware that he was to see Ms Wright in the Emergency Department of the Hospital. He did not attend until between 45 minutes to an hour later.
  10. At 1215 hours, Ms Wright’s blood samples reveled the presence of infection.
  11. At 1230 hours, Ms Wright died.
  12. When Dr Hall arrived between 1245 to 1300 hours, he stated he was annoyed that this had happened without him being phoned. He was advised that he had been telephoned three times and was left with two messages, but responded that it was no good ringing on that telephone as it was flat. He then denied that he had advised RN Honan that he would arrive within 30 minutes after he had telephone the hospital.

Having heard the detailed evidence in connection with the treatment Ms Wright received at Oakey Hopsitla on 26 December 2013, Deputy State Coroner John Lock, concluded, at:

[130]                       There were a series of almost unbelievable errors, misunderstandings and miscommunications, which contributed to this tragic set of events. The nurse looking after Mrs Wright had only one plan and that was for Mrs Wright to be reviewed by the on-call doctor, Dr Hall. She endeavoured to contact him on a number of occasions but his phone was not charged and he did not receive any messages.

[131]                       The failure by Dr Hall to have his phone charged or to advise the hospital of an alternative telephone number was inexcusable, a matter appropriately acknowledged by the Darling Downs Hospital and Health District.

[132]                       Nonetheless the nursing staff should have considered a plan B to appropriately escalate their concerns in the absence of medical staff. This failure was likely due to the fact the seriousness of Mrs Wright’s condition was not recognised by nursing staff. There were a number of opportunities where this could have occurred. An earlier review and commencement of treatment may have resulted in a more favourable outcome for Mrs Wright.

How we can help you

Unfortunately, similar circumstances to the type encountered by the late Ms Wright and her family members happen far too often in public and private hospitals all over Australia, affecting hundreds of Australians, and their families, on a daily basis.

Our highly experienced specialist medical negligence lawyers will be more than happy to assist you and guide you through your claim process and be there with you every step of the way. We routinely act for clients in cases, involving misdiagnosis and failure to diagnose a medical condition, delay in diagnosis of a medical condition resulting in a delay of administration of appropriate treatment, surgical mishaps, poor treatment outcomes and in numerous compensation to relatives, and nervous shock claims, arising out of failures by the medical profession.

If you believe you, or your family member, received negligent treatment at a hospital or through your doctor, treating specialist or dentist, you may be entitled to compensation.

For a free case appraisal call our expert medical negligence lawyers today.

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