Inquest into the Death of Janice May SAULYS
Delivered on :18 May 2016
Delivered at : Perth
Finding of : Deputy State Coroner Vicker
Orders/Rules : N/A
Suppression Order : N/A
Summary : The deceased was 69 years of age at the time of her death. The deceased’s death was not reported to the Coroner because it was not considered to be a reportable death and a death certificate was issued without an autopsy being performed. The family of the deceased were very distressed by her death and became vocal about issues relating the Northam Regional Hospital Emergency Department. The hospital was under review due to difficulties being experienced in resourcing the hospital with respect to its specific circumstances. The family of the deceased were unhappy with the outcome of the various reviews and the Regional Director of the Western Australia Country Health Services requested an inquest be held as an independent review of the cause of the death of the deceased and the circumstances surrounding her death.
On 18 June 2012 the deceased had a fall and was taken to the Emergency Department of the Northam Regional Hospital by her husband. The deceased had sustained a spiral fracture of her left humerus and she was given IV morphine for control of her pain. She was provided with a black slab with collar and cuff and assessed by the occupational therapist. She was discharged later that afternoon.
On the following morning the deceased was still unwell and she returned to the hospital. The deceased presented at the hospital with nausea and vomiting. A note was made of the fact the deceased was susceptible to renal failure and that she was taking Panadeine forte for pain control. While the deceased would not have been admitted to a ward for a broken arm the treating doctor was concerned about her propensity to suffer renal failure as the result of dehydration. The deceased remained in the ED under observation with rehydration and blood was taken for investigation. On viewing the blood results and other observations the deceased was admitted to a ward under her normal GP overnight with IV fluids. The ED doctor did not write a request for repeat bloods on the grounds it was a decision for the deceased’s GP to make the following day, after overnight fluid resuscitation. Despite Mr Saulys wanting the deceased to be admitted to St John of God Hospital the treating ED doctor did not consider it was warranted.
On 20 June 2012 the deceased’s GP reviewed the deceased and was satisfied from her observations of the deceased and her conversation with her that she did not need to be physically examined because she could make a reasonable clinical assessment on the notes and the deceased’s presentation. The deceased had been rehydrated and there was no record of the deceased vomiting since her admission. She was discharged home.
On 28 June 2012 the deceased presented at the Northam Regional Hospital ED where she advised that she had been vomiting for two days and had a sore throat. She was asking to be transferred to St John of God Subiaco as her husband was unable to help her any further due to him also being ill. The ED was very busy with only one doctor on duty. The deceased’s observations were taken and were all within normal range with the exception of her blood pressure which was slightly low. The deceased’s observations were repeated later and her blood pressure had improved to normal range. The hospital had no available beds and was not in a position to admit the deceased to a ward. The deceased’s husband was dissatisfied and contacted the deceased’s GP. The deceased’s GP despite not being on duty in the ED attended to the deceased and her husband. Despite their GP explaining the situation to them the deceased’s husband was insisting that the deceased be transferred to another facility. Arrangements were made for further investigations to be made to determine whether there were clinical reasons to seek a transfer of the deceased to another facility.
Results showed the deceased’s renal function had deteriorated when compared to her results on her 19th June admission. A plan was put in place to care for the deceased while arrangements were made to transfer the deceased to a tertiary institution. On the evening of 28 June 2012 the deceased was delivered to Hollywood Hospital. Once transferred the deceased was successfully cannulated and rehydration continued. The deceased’s kidney failure was corrected but the developing sepsis was not. The deceased’s condition continued to deteriorate and she died.
The Deputy State Coroner was satisfied on the whole of the evidence the deceased was a 69 year old woman with a significant medical history, including a susceptibility to acute kidney failure with dehydration. Effective rehydration was a major concern but needed to be done carefully due to her known cardiac issues. The Deputy State Coroner further found the medical evidence supports the proposition the deceased was experiencing an infective process of some kind towards the end of June 2012 which, with her complicated medical history, certainly warranted investigation and those investigations were instituted on 28 June 2012 despite the deceased not appearing clinically unwell.
The Deputy State Coroner found death occurred by way of Natural Causes.
Following reviews of the Northam Regional Hospital Emergency Department in 2012 a different model of practice was resourced allowing for more extensive medical and clinical coverage.
Catch Words : Management of patients in ED : Patients comorbidities : Natural Causes.
Last updated: 27-May-2016
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