Coroner's Court of Western Australia

Inquest into the Death of June Valerie LOBBAN

Inquest into the Death of June Valerie LOBBAN

Delivered on :7 December 2017

Delivered at : Perth

Finding of : Deputy State Coroner Vicker

Recommendations :Yes

Recommendation No. 1
SJOG Murdoch ensure the SKG Radiologists contact the appropriate consultant under whom a patient is admitted where there is a serious radiological result requiring urgent attention.

Recommendation No. 2
Where the overnight care of a patient has required intensive intervention the clinical nurse manager should ensure that patient receives appropriate medical review the following morning if observations have not warranted a medical review earlier.

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 1 May 2014 the deceased had an elective decompressive laminectomy with rhizolysis vertebroplasty and SMS strut at St John of God Murdoch Hospital. The spinal procedure went well and the deceased was restricted to lying supine with pain relief, IV antibiotics and her regular medications.  On 3 May 2014 the deceased first complained of feeling uncomfortable and it was noted her abdomen was distended.  Nursing staff believed the deceased was suffering from constipation, a known complication of spinal surgery and she was treated according to the nursing postoperative constipation protocols.  This was only partially effective and the deceased complained of extreme discomfort with abdominal pain and nausea and her abdomen was distended and hard to the touch.

A resident medical officer was requested to review the deceased for the prescription of a fleet enema. This was ineffective and the resident medical officer called the deceased’s consultant neurosurgeon to discuss the situation, who advised to contact a gastroenterologist.  When that was unsuccessful the resident medical officer contacted the on-call general physician who advised an abdominal X-ray.  The residential medical officer wrote a request for the X-ray and ordered the deceased be prepared for X-ray prior to the end of his shift.  The deceased was to be reviewed by her treating team in the morning.

The X-Ray was undertaken on the morning of 5 May 2014 and was suggestive of a perforation of the stomach or bowel with no features of intestinal obstruction. There was no indication these X-rays or reports were reviewed by anyone on the deceased’s treating team, nor was the deceased reviewed by her treating team on 5 May 2014.  On the evening of 5 May 2014 a rehabilitation and geriatric consultant reviewed the deceased with the intention she would be transferred for rehabilitation following her spinal procedure.  The deceased was diagnosed with an intestinal perforation and needing urgent surgical review, but the consultant was unable to refer the deceased to anyone at St John of God Murdoch for over 24 hours.  The consultant urgently arranged for the deceased to be transferred to Fremantle Hospital for surgery that night.  The deceased underwent an emergency laparotomy at Fremantle Hospital and a right hemicolectomy was performed.  She had a perforated caecum with patchy necrosis of the caecum and faecal contamination of the peritoneum.  Following this procedure the deceased did not improve and a second laparotomy was performed on 6 May 2014 and an end-ileostomy performed.

The deceased was return to ICU with inotropic support. She developed multi organ failure and peripheral ischaemia and on 9 May 2014 it was agreed that the deceased had distal bowel ischaemia and nothing more could be done.  The deceased died later that night.

The Deputy State Coroner concluded on all the evidence the deceased died as a result of sepsis arising from ischaemia of her caecum and its resulting perforation, however, the Deputy State Coroner was not in a position to determine the cause of the ischaemia, but concluded it would seem to be a whole of situation outcome. The deceased’s underlying conditions, her need for surgery and the necessary immobility following surgery may well all have contributed to a reduced blood flow to her bowel and initiated the later problems.  Although the Deputy State Coroner was unable to say with certainty that had appropriate intervention occurred early on 5 May 2014, this would have changed the outcome in view of all the contributing factors, however, it would have improved the deceased’s chance of survival.

The Deputy State Coroner noted a major concern with the lack of medical cover at St John of God Murdoch over the weekends. The Court was advised that new protocols were now in place and the Deputy State Coroner was satisfied that St John of God Murdoch now have in place a procedure for the reporting of radiological information to persons with the ability to put in place appropriate responses, however, the Deputy State Coroner was minded to make a recommendation for better communication between the radiologists and relevant clinicians.

The Deputy State Coroner made a further recommendation in respect to the timely intervention of a clinical nurse manager to ensure a patient receives appropriate medical review in the morning if observations have not warranted a medical review earlier.

Catch Words : Ischaemic bowel : Underlying comorbidities : Perforation as a result of surgery : Delay in diagnosis of perforation : Response time in reporting of radiological information : Communication between radiologists and clinicians : Timely intervention and review of patients : Natural Causes

 


Last updated: 15-Mar-2018

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