Inquest into the Death of Donald Richard BROADRIBB
Delivered on :28 September 2016
Delivered at : Perth
Finding of : Coroner Linton
Orders/Rules : N/A
Suppression Order : N/A
Summary : The deceased experienced a number of complex health issues including being an insulin-dependent diabetic with a history of depression and prostate cancer which was treated by radiotherapy and brachytherapy. The deceased had experienced a number of additional health issues in September 2012 after he had suffered a fall at home during the night, which left him with a sore right shoulder and he had developed some bruising in his collarbone area and right hip, as well as experiencing some pain around his right-sided lower ribs. On 21 September 2012 the deceased experienced a whole body spasm on his right side. This was on the background of post nasal dripping and less severe spasms during the previous days. An appointment was made for the deceased to see his general practitioner on 27 September 2012.
In the days leading up to the appointment the deceased continued to experience some chest spasms and pain to his right ribs when pressed. He was also experiencing symptoms of depression, insomnia, urinary incontinence and constipation. The deceased attended his appointment with his general practitioner, who thought that clinically it seemed likely that the deceased had fractured a rib during his fall. Blood tests were undertaken and the deceased was treated with anti-inflammatory medication on top of his usual medications. The deceased re-attended to see his general practitioner on 8 October 2012 still reporting pain in his right shoulder and anterior rib. His blood tests results were discussed and they were noted to be normal other than slightly low B12, for which the deceased was given an injection of vitamin B12. X-rays of the deceased’s chest and right shoulder were ordered given that the deceased continued to experience pain. The x-rays were undertaken at the Northam Regional Hospital on 10 October 2012 and both were later reported as normal. An appointment was made for the deceased to see his general practitioner on 15 October to discuss the results of the x-rays.
On 11 October 2012 the deceased was experiencing difficulty swallowing. On the morning of 12 October 2012 he experienced a blood nose and was unable to eat his breakfast. He remained unwell throughout the day and vomited up any food which he had attempted to eat. The deceased presented at the York Hospital in the evening. The hospital did not have a doctor on duty. The deceased was triaged by one member of the hospital nursing staff, and then he was handed over to another nurse, who due to some difficulty obtaining a clear history from the deceased, as well as observations being falsely reassuring, did not identify that the deceased had a rapidly progressive illness. The information the nurse provided later to the doctor at the Northam Hospital, did not enable him to make a proper diagnosis. As a result the deceased was discharged home into the care of his wife.
On returning home the deceased continued to decline and became increasingly distressed. His wife decided to take him immediately back to the York Hospital but before she could do so, the deceased succumbed to bronchopneumonia and acute bronchiolitis at their home.
The Coroner concluded that although the deceased’s condition was potentially treatable, if identified in time, the chest x-ray taken a couple of days before his death did not identify any signs of the infection, which suggests that it may have been a rapidly progressive form of illness. Despite the seriousness of the infection, the deceased was largely asymptomatic until his death. The Coroner noted that this made the diagnosis and treatment even more difficult.
The Coroner found that the deceased died on 13 October 2012 at his home as a result of bronchopneumonia and acute bronchiolitis and the manner of death was natural causes.
Catch Words : Thorough secondary assessment of patients prior to discharge in the physical absence of a doctor : Adequate recording keeping : : Natural Causes.
Last updated: 6-Oct-2016
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