CITATION: Inquest into the death of Ricky Ryder [2007] NTMC 084
TITLE OF COURT: Coroner’s Court
JURISDICTION: Alice Springs
FILE NO(s): A0025/2006
DELIVERED ON: 10 December 2007
DELIVERED AT: Alice Springs
HEARING DATE(s): 18-21 September 2007
FINDING OF: Mr Greg Cavanagh SM
CATCHWORDS: Reportable death at Alice Springs
Hospital, medically adverse event,
hospital resources, preventable death.
REPRESENTATION:
Counsel:
Assisting: Dr Celia Kemp
Department of Health: Mr Kelvin Currie
Dr Raoul Mayer: Mr Roger Bennett
Judgment category classification: B
Judgement ID number: [2007] NTMC 084
Number of paragraphs: 85
Number of pages: 37
1
IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN
TERRITORY OF AUSTRALIA
No. A0025/2006
In the matter of an Inquest into the death of
RICKY RYDER
ON 22 APRIL 2006
AT THE ALICE SPRINGS HOSPITAL
FINDINGS
(10 December 2007)
Mr Greg Cavanagh SM:
INTRODUCTION
1. Ricky Ryder (“the deceased”) was an Aboriginal male born on 14 April 1978
in Alice Springs. He died at 4:08 pm on 22 April 2006 in the Operating
Theatre at Alice Springs Hospital; he was allowed to bleed to death on the
operating table.
2. Pursuant to section 34 of the Coroners Act, I am required to make the
following findings:
“(1) A corner investigating –
(a) a death shall, if possible, find –
i) the identity of the deceased person;
(ii) the time and place of death;
(iii) the cause of death;
(iv) the particulars needed to register the death under the
Births, Deaths and Marriages Registration Act;
(v) any relevant circumstances concerning the death.”
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3.
In addition to this, s 34(2) provides that I may comment on a matter
including public health or safety connected with the death being
investigated. Additionally, I may make recommendations pursuant to section
35(1), (2) & (3):
“(1) A coroner may report to the Attorney-General on a death of
disaster investigated by the coroner.
(2) A coroner may make recommendations to the Attorney-
General on a matter, including public health or safety or the
administration of justice connected with a death or disaster
investigated by the coroner.
(3) A coroner shall report to the Commissioner of Police and
Director of Public Prosecutions appointed under the Director of
Public Prosecutions Act if the coroner believes that a crime may have
been committed in connection with a death or disaster investigated
by the coroner.”
4. Counsel Assisting the Coroner was Dr Celia Kemp (the Deputy Coroner).
Leave was granted to Mr Kelvin Currie to appear as Counsel for the
Department of Health and Mr Roger Bennett to appear as Counsel for Dr
Raoul Mayer.
5. Joan Johnson, the sister of the deceased’s mother, and Robert Ryder, the
deceased’s father, attended much of the inquest and I would like to
commend them for the respect they have shown to the process. They told
me, through Dr Celia Kemp, that the deceased was someone who was happy
and enjoyed life, and was particularly happy when he spent time with his
family.
6. The death was investigated by Senior Constable Steven McGuire and I have
before me a coronial brief in relation to the investigation complied by
Senior Constable McGuire (Ex 3). I also have an additional six exhibits
including the birth certificate of the deceased (Ex 1), the criminal decision
in relation to the stabbing of the deceased (Ex 2), the medical records of the
deceased (Ex 4), some statistics provided by Dr Jacob (Ex 5), a chart
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prepared by Vicki Taylor, the General Manager of Alice Springs Hospital,
detailing the recommendations made in response to this death and what had
been done to implement them (Ex 6) and a medical officer orientation plan
tendered by Vicki Taylor (Ex 7).
7. I heard oral evidence from Dr Jacob Koshy, Dr Manjula Devi, Dr Raoul
Carsten Mayer, Dr Fred Boseto, Dr Jacob Oapillil Jacob, Dr Rod Mitchell,
Mr Ian Bittner, Registered Nurse Alexia Jamieson, Professor Guy Maddern
and Ms Vicky Taylor.
8. I thank Senior Constable McGuire for his careful work and the assistance he
provided to Counsel Assisting, Dr Celia Kemp, in her trip to Alice Springs
to prepare for the inquest. I also thank Vicki Taylor, Dr Meredith Arcus and
the Alice Springs Hospital medical staff for their considerable efforts in
assisting Dr Kemp with the preparation of this inquest. Senior Constable
McGuire was unable to be present for the inquest. Instead I was ably
assisted by Constable Theo Karaminidis, who I also thank, in particular for
his substantial efforts to make sure the family of the deceased were aware
of, and able to be present at the inquest.
FORMAL FINDINGS
9. Pursuant to section 34 of the Act, I find, as a result of evidence adduced at
the Public Inquest as follows:
(i) The identity of the deceased person is Ricky Ryder. He was
born on 14 April 1978 in Alice Springs. The deceased lived
at House 26, Charles Creek Camp, Alice Springs.
(ii) The time and place of death was the Operating Theatre at
Alice Springs Hospital at 4:08 pm on 22 April 2006.
(iii) The cause of death was hypovolemia secondary to a
haemorrhage resulting from the operative exploration of
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multiple stab wounds to the thigh, that is the deceased bled to
death on the operating table.
(iv) Particulars required to register the death:
(a) The deceased was male.
(b) The deceased’s name was Ricky Ryder.
(c) The deceased was an Aboriginal Australian.
(d) The cause of death was reported to the Coroner.
(e) The cause of death was confirmed by post-mortem
examination carried out by Dr Terry Sinton.
(f) The deceased’s mother is Jennifer Johnson and his father
is Robert Ryder.
(g) The deceased did not have an occupation at the time of
death.
(h) The usual address of the deceased was House 28, Charles
Creek Camp, Alice Springs.
CIRCUMSTANCES OF DEATH
Events leading up to the hospitalisation
10. The deceased was the victim of a stabbing that occurred in the evening of 21
April 2006. Benjamin John Hayes, Charles Hayes and Earl Harry Matthew
Hayes pleaded guilty to aggravated unlawful entry and causing grievous
harm in relation to their actions against the deceased. They were sentenced
by Justice Thomas of the Supreme Court of the Northern Territory sitting at
Alice Springs on Wednesday 18 October 2006. Her sentencing remarks
were tendered to me (Exhibit 2). I rely on the facts of the matter as found
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by Her Honour to the criminal standard of proof (beyond reasonable doubt)
to set out how the deceased became injured. These were not a matter of
contention at the inquest, and are summarised as follows.
11. Late in the morning of Thursday 20 April 2006 the deceased was at the
Riverside Hotel in Alice Springs. Charles Hayes (aged 20) and Benjamin
Hayes (aged 17) were also at the Hotel. There was a history of animosity
between the Hayes family and the family of the deceased. There was a
verbal altercation between the deceased, on one side, and Charles and
Benjamin Hayes, on the other. Threats of physical violence came from both
sides.
12. Charles and Benjamin Hayes returned to the Hidden Valley camp via mini
bus with a group of others, after consuming a quantity of alcohol. They
were very angry about what had happened at the Hotel and were openly
discussing how they intended seeking out the deceased and stabbing him.
Charles Hayes produced a knife at Hidden Valley Camp and told a witness
that he was going to Charles Creek to stab the deceased. Benjamin Hayes
armed himself with a 2 foot long steel pipe which he told witnesses he was
going to use on the deceased.
13. Sometime that afternoon Charles and Benjamin Hayes went to the
deceased’s house. However he wasn’t at home and they returned to Hidden
Valley. At about 8 pm that evening Charles and Benjamin Hayes again left
Hidden Valley Camp in a V6 Commodore. They picked up Earl Hayes,
Gavin Hayes and Tristan Hayes. Charles Hayes also had a score to settle
with Cameron Smith who lived at Amoonguna Community. Charles and
Benjamin were still respectively armed with the knife and metal pipe.
14. The group drove to Cameron’s Smith’s residence. Charles stabbed Smith
and Benjamin hit him with the metal pipe. The group then left. A sixth
male, Kerry Patrick, got into the car. They went to House 26 Charles Creek
Camp. Charles and Benjamin got out of the car, carrying their respective
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weapons. The deceased responded to a knock at the door and came to the
door. He then turned away to go back inside and Charles, Benjamin and
Earl followed him inside. Charles Hayes stabbed him numerous times.
Benjamin Hayes struck him with the metal pipe. Earl Hayes stabbed the
deceased once in the right back shoulder with a small knife he found in the
car. The group then fled the scene.
15. Police arrived at House 26 at 3 am on Friday 21 April 2006. St John
Ambulance officers were dispatched at 3:02 am and arrived at Charles Creek
at 3:19 am on Friday 21 April 2006. The deceased was lying on the floor
with visible stab wounds and approximately 100 ml of blood around him and
his clothes. He was bandaged and transported to the Alice Springs Hospital.
He was conscious the entire time.
Events during the Hospitalisation
16. The deceased arrived at the Emergency Department at 3:39 am on Friday 21
April 2006. He was examined by Dr Zoe Rodgers, a Registrar in that
Department. She was not called at the inquest and I am relying on her notes,
and the interview she gave to police. She found that the deceased was
conscious and haemodynamically stable (that is, his blood pressure and
pulse rate were stable). She diagnosed a fracture to the left hand. She also
described a number of stab wounds; one to the left elbow, one to the back of
the left hand, one to the left clavicle, one to the left scapula and three to the
left thigh. She described the three thigh wounds; one was ‘proximal and
anteromedial’ (that is closer to the groin and on the front and toward the
midline) and she describes this as ‘2cm, deep, appears to be arterial
bleeding’. The second was also on the proximal thigh but lateral and she
describes this as ‘3cm, deep, venous ooze’. The third was on the
‘posterolateral proximal thigh’ (that is on the back and away from the
midline) and she describes it as ‘2cm’.
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17.
Dr Rodgers ordered various blood tests and in addition sent a sample of the
deceased’s blood for a ‘group & hold’ to the Pathology Laboratory. A
‘group & hold’ is a pre-transfusion procedure where the blood of an
individual is examined to determine its blood group and to see if it has
antibodies which would cause problems for transfusion. It is something that
must be done before blood is provided, and doing it in advance means that
blood can be provided more quickly if it is needed. There are strict demands
for labelling in order to ensure that the blood is identified correctly; the
ordering person has to fill out a form, which has to be signed twice, and
countersigned by a witness and the ordering person has to label the blood
sample itself and sign that also. In this case Dr Rodgers filled in the form
correctly and the witness signed the blood sample but Dr Rodgers herself
did not sign the sticker on the blood sample.
18. The sample arrived in the Laboratory at 4:30 am on 21 April 2006. The
Laboratory rejected the request for a ‘group & hold’ on labelling grounds.
The laboratory posted the fact that the ‘group & hold’ had not been done
onto the hospital computer system as follows:
BLOOD TRANSFUSION MISMATCH
No collectors signature on specimen. Please forward a new specimen
and request for Pretransfusion testing if still required.
It then goes on to describe the requirements for the sample to be accepted.
To see this posting, the person checking on the hospital computer system is
required to go to a screen where all the blood test results are and then click
on the part saying ‘group & hold’ which brings up the screen saying that it
hasn’t been done. There is nothing on the initial screen, which shows that
the ‘group & hold’ has been sent, that would alert someone to the fact that it
had not been done.
19. Dr Rodgers requested General Surgical and Orthopaedic reviews, and the
deceased was seen by both teams that morning. The Orthopaedic team
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determined they needed to operate on the fractured left hand and the stab
wound on the left forearm. The deceased was seen by the general surgical
registrar, Dr Raoul Mayer, and an intern at about 9:15 am that morning. Dr
Mayer had started as a surgical registrar at Alice Springs Hospital at the
beginning of 2006. He was a first year registrar on the advanced surgical
training program for General Surgery. Dr Mayer correctly determined that
the three stab wounds to the left thigh needed surgery. The deceased was not
seen by the surgical consultant who was on that day, Dr Boseto, however Dr
Boseto was told that the deceased was going to be operated on that day. Dr
Boseto has been a consultant general surgeon at the Alice Springs Hospital
since February 2005. He had excused himself from the ward round that
morning to attend his Friday morning clinic.
20. Dr Jacob Koshy, a senior anaesthetic registrar, reviewed the deceased at
about 10 am that morning. He was working as the ward anaesthetist at that
time. His job was the pre-operative evaluation of patients, that is examining
patients scheduled for operations and preparing them for the operation from
the anaesthetics point of view, including ordering any necessary
investigations. Dr Koshy assumed a ‘group & hold’ had been done because
he looked at the computer screen with the general blood results, which
showed that it had been sent away. He did not click on the icon itself.
21. Dr Koshy gave evidence at the inquest that he considered the deceased a low
bleeding risk, because his blood pressure and heart rate were stable and he
had not required many fluids on the ward. His statement indicates he also
relied on the opinion of the surgeons that the operation was not one with a
significant bleeding risk. He gave evidence that had he considered that the
deceased was at a greater bleeding risk he would have made sure a ‘group &
hold’ had been done (that is by checking the screen) and he would have
arranged for a ‘cross match’ to be done. A ‘cross match’ is the same as a
‘group & hold’, but in addition some blood from the patient is actually
mixed with the potential donor blood to see if it is compatible. After this
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the blood is immediately available, however the down side is that once this
occurs the donor blood cannot be used for another patient.
22. The operation did not occur on Friday 21 April 2006 but was delayed. There
are no notes on the deceased’s medical file at all in relation to who made
this decision and why. Dr Jacob gave evidence that the decision to defer it
was made by two surgical registrars, who were not called at the inquest.
They did not inform their consultant and Dr Boseto was unaware that the
case had been postponed. The decision was made for two reasons; the first
was that the deceased had drunk some water and the second, more
significant reason, was that there were too many emergency cases that day
for the theatre time available. Six other cases were also deferred for that
reason on that day. The first was not sufficient reason to delay the
operation and I heard evidence that the operation could have occurred
regardless of the water consumed. However the fact that there were too
many emergency cases for the available theatre time was something out of
the control of the surgeons.
23. The operation was rescheduled for the morning of Saturday 22 April 2006.
Alexia Jamieson was acting as senior anaesthetic nurse on the day. She was
the most senior nurse present and thus in charge. She had been working at
the Alice Springs Hospital for 19 months. There were also three additional
nurses present. I heard evidence and accept that four nurses is the number
required for this sort of operation and thus there were enough nurses present
when it commenced.
24. The deceased was brought to theatre after another person with the same first
name had been called for. The mistake was picked up by Nurse Jamieson
after the deceased was already being prepared for the operation. Nurse
Jamieson gave evidence that the deceased’s correct consent form and notes
were present so he was being prepared for the right operation. It would
clearly have been of much greater concern had the wrong notes been present.
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Although still a matter for concern, I find that this mistake did not
contribute to the death in any way. This mix up in fact meant that the
deceased was operated on earlier than he would otherwise have been.
25. The surgeons responsible that Saturday were Dr Raoul Mayer, the same
registrar who had examined the deceased on the Friday, working for Dr
Boseto, a consultant. The preoperative assessment was conducted by Dr
Mayer. His notes state that the anterior thigh was swollen and quite diffusely
tense esp. laterally over the lateral inferior stab wounds. In evidence he
said that compared to the day before it may have been slightly more swollen,
but that’s a subjective assessment and certainly very hard to quantify (p 34
transcript). The notes made by his intern the day before state leg swollen.
Nurse Jamieson gave evidence that Dr Mayer had said, whilst examining the
thigh, that it had swollen a lot more overnight than he had anticipated. I
find based on this, as well as Dr Mayer’s notes, that it is likely that the thigh
had swollen to some degree overnight.
26. Dr Mayer shaved the groin and prepared it with disinfectant, but did not
drape the patient so that the area in the left groin over the femoral artery
was fully exposed. He says in hindsight it would have been preferable to
have draped it so it was exposed (this would be done to enable quick access
to the femoral artery in the case of severe bleeding). Dr Mayer didn’t check
that a ‘group & hold’ had been done. He gave evidence that if he had his
time again he would have checked the ‘group & hold’ had been done.
27. Dr Boseto did not see the deceased before surgery started, and was not
present when it did start. He did not have any contact with the deceased
before the operation. He was informed by his registrar, Dr Mayer, that the
operation was going ahead and told Dr Mayer that he was happy for the
registrar to do it. He gave evidence that this was on the basis that he’s done
a few similar cases, and this is a wound on the lateral thigh and based on
his assessment he was happy to go ahead and I told him ‘Yes’ (p 50
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transcript). Dr Boseto was in the Doctor’s room, which is opposite the
theatre tea room, when the operation commenced. He said that if I had this
again in the benefit of hindsight I think it’s my duty to see every patient
beforehand (p 51 transcript). He said he was not aware that the thigh was
swollen, nor that there had been a concern about arterial bleeding (as noted
by Dr Rodgers on admission) and these things would have been important
for him to know. It is important to note that Dr Boseto was Dr Mayer’s
supervisor in relation to this surgery.
28. The anesthetist was Dr Manjula Devi, a senior anaesthetic registrar. She
had been in Australia for four months, working as a senior registrar at the
Alice Springs Hospital. She had qualified and previously worked as an
anaesthetist in India. She first became involved with the deceased’s care at
about 9:45 am on 22 April 2006 when she examined the deceased before he
went to theatre. She continued making notes on the Anaesthetic Record
which had been used by Dr Koshy the day before. She gave evidence that
she assumed the case did not present a particular bleeding risk. She formed
her opinion based on what the patient said, the stable observations of the
patient and Dr Mayer’s description of the surgery as a washout that wouldn’t
take long from the surgery point of view (p 17 transcript). Dr Mayer was
asked about this and can’t recall specifically telling Dr Devi this, but says
that he may have, as this assessment was not out of line with what he was
thinking. The thigh was covered by a pressure bandage and she didn’t see it.
Dr Devi says that she did not check whether the ‘group & hold’ had been
done because she assumed it had been. She said if she had anticipated any
problems then she would have checked it and that in retrospect she should
have checked it. She said that had she been told things that indicated a
greater risk of bleeding (such as that the thigh was swollen or that the
original notes queried whether there was arterial bleeding or that it was
anticipated that the operation would take a while) then she would have taken
greater precautions. She would have talked to the blood bank and made sure
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blood was available. She would probably have put in a more invasive
monitor and she would have informed her consultant that she was
anticipating bleeding.
29. The orthopaedic side of the operation commenced at 10 am and was
completed uneventfully. Dr Mayer started operating on the thigh at about
10:35 am. He commenced exploring the thigh wounds however about 20
minutes into the operation he discovered that the bleeding in the lateral
inferior wound was going to be difficult to control and he called for Dr
Boseto.
30. Dr Boseto arrived promptly at about 11 am. Dr Mayer stated that during his
part of the operation there was very minimal bleeding, and the bleeding
really started after Dr Boseto came in and, appropriately, extended the
wound. Dr Boseto says that when he came there was some bright red
bleeding and venous bleeding, but nothing really torrential. (p 54
transcript). The inferior lateral thigh wound was the one with a lot of
bleeding. Dr Boseto took over the operation and Dr Mayer became the
assistant. Dr Boseto immediately extended the excision in order to access
the bleeders and close them with suture ligation. He said that when he did
this, and removed some clots, there was a lot of bleeding. Dr Mayer
describes it as profuse bleeding, both arterial and venous, from deep behind
the bone in the thigh which is a difficult place to access (p 35 transcript).
The two used repeated packing and coagulation diathermy to try to control
the bleeding. The wound bled actively for at least 40 minutes, which was the
time taken to control the more serious bleeding. Thereafter the wound
continued to ooze blood for an hour and a half. I find that the major part of
the blood loss occurred between 11 am and 12 am, and that blood continued
to be lost at a slower rate for the next hour and a half thereafter.
31. At about 11:20 am the deceased became haemodynamically unstable (that is
his blood pressure fell and his heart rate went up) because of the blood lost.
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Dr Devi recognised this straight away. She put in an extra line and she
asked Nurse Jamieson, the anaesthetic nurse, to go and ring the pathology
laboratory and see if any blood was arranged. She gave evidence that she
didn’t call herself because there was no phone in theatre (the nearest phone
was about 3 m away and outside the theatre) and she did not want to leave
her patient. Dr Devi said that she also did not know the phone number for
the pathology laboratory, and it wasn’t up on the wall, so she would have
had to go through switch which would have taken extra time.
32. Nurse Jamieson called the pathology laboratory and reported back to Dr
Devi that blood hadn’t been ‘group & held’. Dr Devi then requested 4 units
of blood by taking a blood sample, filling out a form and asking for them to
be sent across to the laboratory so that blood could be cross matched and
provided. Dr Devi records that blood was requested at 11:45 am. Nurse
Jamieson says she rang the laboratory to tell them the blood was coming
over. The laboratory is about 300 m away from theatre so ‘rovers’ come and
collect the units from theatre and deliver the specimens.
33. Dr Bittner is the manager of the pathology laboratory at Alice Springs
Hospital and was working on the morning of Saturday 22 April. He says
that the laboratory received a request form for 4 units of blood for Ricky
Ryder. Dr Devi had used the wrong form; she had used the routine
pathology request form rather than the special one for transfusions. On the
form she had used she had not signed her name in the place for the signature
of the collector. There was not a place for a witness to sign on the form,
because it was the wrong form, and there was thus also no witness signature.
Dr Devi was asked about this error in court and said there were two reasons
for it; the first was that this was the first time she had filled out a blood
request form since working at Alice Springs, previously this had already
been done by the surgeons, and she was never oriented about how to fill out
the form. The second reason was that she was in a hurry. She said that she
wasn’t aware that the ordering form needed two signatures. Nurse Jamieson
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was asked about this and said it would normally be the case that as the
witness she would sign the form, but she didn’t. She said that she didn’t
pick up on this as it was a very difficult time in that they were trying to do
several things at once.
34. The sample was received by a 17 year old employee at the front desk, who
consulted her senior. The laboratory, following its guidelines, rejected the
form. There is some dispute on the evidence as to whether the young
employee rang Nurse Jamieson to tell her that the form and sample weren’t
correct or whether Nurse Jamieson rang to ask where the blood was and was
then told that the form and sample weren’t correct. Nurse Jamieson asked if
the rover could take the same sample back and the young employee told her
that it was against their procedures. Nurse Jamieson sent the rover anyway
who arrived. An argument then ensued on the phone between Nurse
Jamieson and the employee.
35. Dr Bittner was involved in this decision making and says that after a lot of
telephone calls asking us where the blood was and what we were doing I
actually made a decision to accept the request form and the specimen in its
original form. He said he made this decision at about 12. The ‘cross
match’ was then done, and the blood was available at about 12:30. His
records show that it was picked up by the courier at 12:45. There are some
discrepancies in the evidence as to when the blood arrived, I find it is likely
that the blood arrived in the operating theatre at about 1 pm and that
transfusion began within the next half hour.
36. During the wait for blood Dr Devi gave the deceased about 3.5 L of fluid,
placed more peripheral lines in and tried and failed to get an arterial line.
She did not call for senior help. The deceased wasn’t given any repeat doses
of antibiotics. The weekend arrangement was that there were two
anesthetists on call, the first on call was Dr Devi and the second was a
consultant, Dr Rod Mitchell. Dr Mitchell had been called in for another
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matter at 10:30 am and then left at 11 am. He was then called in at midday
for an anaesthetic emergency (an acutely swollen airway that needed
intubation) and was in fact in the adjacent theatre dealing with that from
about 12:30 pm to 1 pm. This theatre was about seven metres away from the
theatre the deceased was in. He had arranged to do some teaching at 1 pm
so had arranged for Dr Isaac Muthiah, another consultant, to cover him from
that time. Dr Mitchell called Dr Muthiah in before 1 pm to help assist with
the intubation. Shortly after 1 pm Dr Mitchell left the hospital and Dr
Muthiah stayed with the patient for two further hours while they waited for a
free bed in the Intensive Care Unit.
37. Despite the presence at different stages of consultants in the adjacent
theatre, the first any anaesthetist other than Dr Devi heard about difficulties
with the deceased was when Dr Devi called for senior anaesthetic assistance
from Dr Muthiah. It is unclear exactly when this happened, the internal
anaesthetic review says about 3 pm, Dr Devi thought it was more like 1:30
or 1:45 pm, and Dr Muthiah was not called to give evidence on this point. I
find it was likely to be after 2 pm, that is after the surgeons had left. Dr
Devi says that she was aware that if there was any problem with a patient or
she was able to call the consultant and that there was no pressure not to call
a consultant. However in this case her perception was that she couldn’t call
for help because her senior was involved in another case which was an
emergency. Dr Mitchell gave evidence that Dr Devi could have called him,
even if he was in the middle of another emergency case. He also said that
Dr Devi could have called for help from another consultant, not officially on
call, if the first one was not available. Dr Devi says she was not aware of
this. In addition she says she thought that all the anaesthetic consultants
were unavailable because she knew there were trial exams being conducted
that day. Dr Mitchell says that he wishes he had stuck his head around the
door on the day, but also that he should be able to rely on his registrar to
call him if there were difficulties.
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38.
Dr Boseto also became concerned about the loss of blood. He says he asked
several times how the patient was and got a positive response each time, the
sixth time he was told to concentrate on the surgery and that the
resuscitation aspect would be dealt with by the anaesthetic team. Dr Mayer
says that Dr Boseto frequently inquired from Dr Devi whether or not the
patient was stable and each time there was a positive answer. He says that
Dr Devi did not tell them at any point that she was having trouble keeping
the patient haemodynamically stable. Dr Mayer was asked whether Dr Devi
was told at any stage that the surgeons were having difficulties controlling
the bleeding and he couldn’t recall. Dr Boseto says he never told Dr Devi
that he was having difficulty controlling the bleeding. Dr Devi said that Dr
Boseto kept asking her if the patient was stable and she told him that the
patient was unstable, she was unhappy about it and she needed blood. Dr
Boseto says he never heard that. Dr Devi can’t remember being told that the
surgeons were having difficulty controlling the bleeding. Nurse Jamieson
says that Dr Boseto was not clear in stating how much blood had been lost
and she heard Dr Devi ask twice about this. Given all the contradictions
here I am unable to find exactly what was said by those present but I find
that communication between the anaesthetists and the surgeons about the
respective difficulties each was having was not clear.
39. There are 8 units of O negative blood (blood that can be given to people no
matter what their blood type) kept in a fridge in the Emergency Department,
for anybody to take when needed, in case of emergencies. It appears nobody
thought to use it. Dr Devi said that she expected the blood to come, she had
sent the sample around 12 and it usually takes around half an hour to 45
minutes, so she didn’t think of using O negative blood then. She said that
she didn’t know it was available in the fridge and in her previous practice
overseas the O negative blood was held in the pathology laboratory.. She
was not told when she came to Alice Springs Hospital that it was kept in the
fridge. She gave evidence that she had only become aware of the fact that O
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negative blood was stored in the emergency department when she was told
by Dr Kemp as part of proofing her for evidence a few days before the
inquest. Dr Boseto also did not call for the blood. He was asked about
whether he thought to use it and he said it never crossed my thoughts
actually (p 58 transcript). He also gave evidence that he was not aware that
it was available for general emergency use in the fridge in the emergency
room, and had never been told that. He had previously worked at the Prince
of Wales Hospital and said that he was not sure if it was available in the
emergency department there. He said in retrospect that it would have been a
good idea to ask for it.
40. Dr Devi said she felt she had a lack of nursing support on the day. Her
anaesthetic nurse, Alexa Jamieson, had to leave to phone the pathology
laboratory, and then to arrange the second theatre for the emergency. In
addition Nurse Jamieson took a lunch break of between thirty and forty
minutes at 12:20, while they were waiting for the blood to arrive. Nurse
Jamieson gave evidence that she considered lunch breaks important as there
were seven cases booked that day and the nursing staff were looking at a 15
to 16 hour day. However knowing what she does now, she regrets having
taken the break. She said that when she returned to the theatre, Dr Mitchell
was in the corridor and informed her about the patient requiring an
emergency intubation. She needed to set up theatre for that. It is clear that
more nurses were needed once the second emergency case arrived, however
no additional nurses were called in. That would have been the responsibility
of Nurse Jamieson. Nurse Jamieson stated that she didn’t have time to make
a phone call to the managers of the hospital who would know which staff to
call in, the experienced anaesthetic nurses. She gave evidence that if she
had had the luxury of time she would have made phone calls, however as
nobody was on call she would have to ring around until people agreed to
come in. She said it might have taken her half an hour to find someone. She
said that there was no one else to call as the other nurses were all required
18
for the operation on the deceased. She said having a phone in theatre would
have helped.
41. Nurse Jamieson did not mention to any of the medical staff next door that
there were any concerns about the patient. She said that she did not do so
because it was an emergency situation and she didn’t want to defocus them
from that situation.
42. When the blood arrived it was given to the deceased. Dr Devi gave evidence
that she would have been able to give it faster if she had had either a second
anaesthetist present, or a rapid infuser.
43. The General Surgeons finished up at 1:50. They packed the wound tightly
to control ooze with the intention of coming back later when the patient was
stable, and possible clotting problems had been resolved, to close properly.
They left within about ten minutes of finishing. Dr Devi stayed with the
deceased. Dr Boseto was asked about leaving and whether he considered that
at that time Dr Devi needed more help. He said there was no panicking at
all at the time, and we’d completed our – what we needed to do in terms of
controlling the bleeding. It seems on the surface that things were ok – were
fine, and so we had other patients to see; myself and Dr Raoul and therefore
we left…And then we knew that an – extra hand was – help was next door (p
61 transcript).
44. At 3:20 pm the surgical team was called in to re-explore because despite all
the blood being given to the deceased he was not responding. The team
clamped the common femoral artery and then explored the two thigh
wounds. Neither had bled. This means that the blood that was lost was lost
before 1:50 pm.
45. A code blue occurs when someone is almost arresting or has an arrest (that
is their heart stops) and means a specified group of doctors all drop
whatever they are doing and arrive to help the patient. A code blue was
19
called at 3:40 pm. CPR was started at 3:45 pm. There were some
difficulties calling the code blue. Nurse Jamieson gave evidence that she
pressed the button but it didn’t stay in, which it is supposed to do to indicate
that it is working, and calls were not made to everybody who needed to be
called. There were no regular tests of the system at that time. Nurse
Jamieson ended up making a priority call to he surgeons and then asking
switchboard to call other doctors, and they did arrive. However the
deceased was unable to be resuscitated and was declared dead at 4:10 pm.
Expert Evidence
46. I was very impressed with the evidence given by Dr Jacob, the Director of
Surgery at Alice Springs Hospital. He has extensive experience with stab
wounds and I was very much assisted by his expertise. He had thoroughly
looked into the circumstances of this case and I found him to be an honest
and knowledgeable witness. His evidence was of great assistance to me and
I accept it fully.
47. Dr Rod Mitchell, the Director of Anaesthetics at Alice Springs Hospital at
the time of this death, also gave evidence from Queen Elizabeth Hospital in
Adelaide where he is currently located. He also thoroughly reviewed the
case from an anaesthetic perspective and I find his review was thorough and
honest, and I put significant weight on his evidence.
48. I also heard from Mr Bittner, the head of the pathology laboratory, and also
found him to be a very honest and extremely helpful witness.
49. Finally, Professor Maddern wrote a comprehensive report for the Alice
Springs Hospital on the factors that contributed to this death. I accept his
report and it has been of significant assistance to me. Professor Maddern
was called to give evidence. In his evidence he seemed to repeatedly depart
from his report in a way that attributed less blame to the surgeons involved
and greater blame to all the other specialities. However each time the
20
discrepancy was pointed out to him, he accepted his opinion as expressed in
the written report. Consequently I prefer his written report where it differs
from his oral evidence.
MEDICAL CAUSE OF DEATH
50. It is clear that the operation was necessary and the decision to operate was
correct. If it had not occurred the deceased is likely to have developed an
infection and become septic and, without treatment, died. In addition the
clot that was stopping him bleeding may well have dislodged and caused
serious bleeding.
51. I find that the deceased lost six to eight litres of blood and that ultimately he
died from hypovolemic shock. There was evidence that the deceased was
coagulopathic, that is his blood was no longer able to clot. There may also
have been some contribution to his death by a degree of sepsis. The forensic
pathologist conducted an autopsy which did not find any alternative cause of
death.
52. It is accepted that this was an avoidable death and should not have occurred.
The fact that this death was preventable was immediately recognised by the
Alice Springs Hospital staff and they put a considerable amount of work and
thought into analysing what happened and trying to prevent it recurring.
This included engaging Professor Guy Maddern, a surgeon from Adelaide, to
conduct an independent, external review and co-operating fully with it.
Professor Maddern gave evidence he that was very impressed with the
openness of the hospital. In addition reviews were conducted by the
Department of Surgery and the Department of Anaesthetics. The reviews
were frank and thorough and I have found them of considerable assistance in
preparing these findings. I would like to commend as outstanding the
hospital’s proactive approach in response to this death and their cooperation
with the Coroner’s office in investigating it.
21
53.
Ms Vicki Taylor, the General Manager of Alice Springs Hospital, gave
evidence before me. As part of this she told the family of the deceased on
behalf of the Hospital that we are extremely sorry that this had occurred… I
think it is important when these sorts of things happen that we reflect on our
practice. We take our duty of care to the Alice Springs community very
seriously, and an opportunity to improve our practice is a very important
one for us to take which is why we responded as we did. (p 136 transcript)
54. Alice Springs has the highest reported incidence of stab wounds in the
world. There were 1440 cases there in a seven year period. Most of the stab
wounds are in the thigh, because of cultural practices, which is something
unique to Alice Springs. The deceased himself had previously presented on
multiple occasions with stab wounds. I thus consider it particularly
important to cover in detail factors that contributed to an avoidable death
from this particularly common presentation.
FACTORS THAT DID NOT CONTRIBUTE TO DEATH
55. Dr Bittner gave evidence that the strict labelling requirements that caused
the samples to be rejected come from a national guideline that enforces very
rigid requirements for the identification of a patient sample for pre-
transfusion testing. (p 103 transcript). He described how if the wrong type
of blood is given it can be fatal, and stated that blood is not given without a
serious amount of thought and protocols are in place to ensure that people
are given the right type of blood. There are one to two incompatible blood
transfusions a year in Australia which is why the Australian Society of
Blood Transfusion Group set the guidelines so rigidly. He said there are
particular concerns in the Territory because indigenous patients often come
in under different names, the dates of birth are not reliable, and the address
is often given as care of a community. Overall there is a trouble getting
reliable indicators of identity for indigenous patients. He said [w]e were
recently examined by the accrediting authority, NATA, and they insisted that
22
we reject samples if the time of collection wasn’t put on the specimen tube.
And that’s very, very rigid. You don’t get those sorts of requirements for
any area other than transfusion (p 103 transcript). The laboratory thus has
a zero tolerance policy when it comes to pre-transfusion specimen labelling.
If the specimen and the request form do not meet the requirements they are
to be put in the bin. The laboratory does not send samples back to be signed
properly, nor does it allow staff to come to the laboratory and correct errors
in the forms.
56. I accept these requirements are appropriately strict and that in both cases the
sample of the deceased’s blood was appropriately rejected. In this case Mr
Bittner made an exception at midday, he decided that even though the
paperwork was inadequate, the specimen was correctly labelled, it had the
collector’s signature and it was handwritten, and the deceased had previous
records which meant the pathology department knew his group. This
breached Mr Bittner’s own protocols. He said he has made such an
exception only on one other occasion in two years. He gave evidence that
had he not been there, the staff would have had to contact the Director of
Pathology at Royal Darwin Hospital and would have been told that they
could not use the specimen.
57. I therefore find that the strict requirements of the laboratory are appropriate
and are not a contributing factor to the death. It is because the requirements
are so strict that a correct sample should be sent in advance to be ‘group &
held’, so blood is quickly available if required, and blood should be cross
matched in advance if there is a risk of serious bleeding. In addition the
laboratory provides O negative blood for emergencies.
FACTORS THAT CONTRIBUTED TO THE DEATH
The delay of the operation from the Friday to the Saturday
23
58.
I find that the delay of the operation to the Saturday contributed to the death
for two reasons. Firstly, because it moved the operation from occurring in
hours, when there is a lot of support around, to out of hours, when there are
significantly less staff working, and this negatively affected the nursing
support available, the anaesthetic support available and the operations of the
laboratory. Secondly, because it is likely that the delay made the operation
more difficult. I heard evidence that firstly the delay would have increased
the chance of infection, secondly it meant clotting factors were more likely
to have been used up – and thus bleeding was more likely, and finally it left
more time for there to be bleeding into the muscle, and for there to be tissue
oedema, which meant that the muscle was harder to retract and thus it made
the operation more difficult and the control of bleeding more difficult. Dr
Jacob said that it is better to do this sort of operation within six hours of
presentation. He said that it is likely that the knife used to stab the deceased
was not clean, which means there is an increased chance of infection. Dr
Mitchell agreed that with the dirty wound, delay allowed time for infection
to take hold. (p 88 transcript). Dr Jacob stated that it may have been easier
to control the bleeding if it had been done on the Friday. Dr Mitchell went
so far as to say that the deceased would not have passed away had the delay
not occurred.
The underestimation of the bleeding risk presented by the operation
59. I find that the surgical team underestimated the bleeding risk presented by
the operation. Dr Jacob gave evidence that the sort of injury the deceased
had on his upper thigh is always a difficult one because it can actually –
some of the knives are quite long. It can go all the way posteriorly and cut
one of the vessels – what we call the deep femoral artery – which is
extremely difficult to control (p 73 transcript) He said that the location of
the stab wound have made him concerned that the operation may be
complicated. He said that the fact that the thigh was swollen should alert a
surgeon to the fact that this was a major injury. This meant that the groin
24
should have been properly draped for instant access to the femoral artery,
and blood should have been cross matched. Two surgeons were required
because if we are to explore the back of the thigh you can’t do it alone...one
doctor cannot do that by himself even with the assistance of the nurse
because [the patient] needs to be turned to one side [to] explore into the
depth of the tissues. You need…two sets of hands (p 74 transcript). Dr
Jacob said that if he had seen the case and the anaesthetist had asked him the
bleeding risk he would have cautioned them that it may be a bleeding risk.
60. The junior surgical registrar started the operation by himself. His consultant
was nearby, but not present, and did not examine the patient himself before
the operation. I find that had a more experienced surgeon seen the patient,
the location of the wound, the fact that it appeared deep and the fact that it
was swollen, and the fact that there was some arterial bleeding at the time of
admission, would have alerted them to the possibility of serious bleeding
during the operation. I find that the registrar was too junior to accurately
assess the likely bleeding risk. He had operated on four to five stab wounds
only before this one, all at the Alice Springs Hospital. I find that he
underestimated the risk and because of this did not take precautionary
measures that should have been taken. This would have meant fully draping
the femoral artery, at the least checking that the ‘group & hold’ had been
done (and preferably ensuring that blood was cross matched) and making
sure two general surgeons were present at the start of the operation. I do not
find that any of this was the fault of the junior registrar; he had only been
working as a surgical registrar for four months and had limited experience
with stab wounds. The responsibility for this lies with the consultant who
should have seen his patient before the operation started, and been present to
supervise his junior registrar at the start of the operation.
61. I also find that both anaesthetists who assessed the patient underestimated
the bleeding risk and I find that the main reason for this error was that both
of them, appropriately, relied on the opinion of the surgeon, in this case the
25
junior surgical registrar, as to that risk. I find that had a more senior
surgeon reviewed the patient, recognised the risk and made Dr Devi, in
particular, aware of it then she would have taken precautions such as having
blood cross matched, using more invasive monitoring and informing her
consultant that the operation may be difficult. Dr Mitchell said had he been
the anaesthetist and informed of a significant bleeding risk, he would have
cross matched blood and put in a larger line.
Failure to check that the ‘group & hold’ had been done
62. I find that even though the anaesthetic and surgical registrars operating on
22 April 2006 underestimated the bleeding risk, based on what they knew
they should have checked that the ‘group & hold’ had in fact been done.
They failed to do this.
Time taken to control the bleeding
63. I find that it took too much time to control the bleeding in the thigh wound
once it began to bleed actively. Dr Jacob gave evidence that 40 minutes is a
long time to control a bleed. He described options to control the bleeding;
exposing the femoral artery and putting a sling on it (‘clamping the femoral
artery’) to stop blood flowing through it or packing the wound and waiting
for blood to come. Professor Maddern gave evidence that if significant
amounts of blood were being lost it would be appropriate to pack the wound
to control it and not explore the wound further until the blood had arrived. I
find that either clamping the femoral artery or packing the wound and
stopping exploration of it would have been better than continuing the
operation while the patient became increasingly unstable. I find that the
surgeons underestimated the seriousness of the situation and, in particular,
underestimated the amount of blood lost.
The failure of the anaesthetist to call for help
26
64.
Dr Mitchell gave evidence that the deceased should have been given more
fluids, perhaps up to six, seven or eight litres of fluid. In addition sepsis
should have been considered and the antibiotic coverage broadened. O
negative blood should have been called for and used. After the group
specific blood arrived assistance would have enabled it to be delivered more
quickly. Overall it is clear that the anaesthetic registrar needed help to
manage the patient appropriately. Professor Maddern found that the
subsequent attempts to manage a significant haemorrhage associated with
the operation were all appropriate but somewhat delayed. This delay was
largely due to the fact that there were too many tasks for one anaesthetist to
perform in such a rapidly deteriorating and crisis environment. (p 4 of his
Report). However the registrar did not call for help until some time after 2
pm. I find that this was partly because she perceived that her consultant on
call that day was involved in another case next door and that she could not
interrupt him, and partly because she was not aware that she could call for
help from other consultants even if they were not on call. However I also
find that the anaesthetist underestimated the seriousness of the situation of
the patient, and in particular she underestimated the amount of blood lost.
The failure to use O negative blood
65. The pathology department continually maintains 8 Units of O negative blood
in the fridge of the Emergency Department. Both the senior anaesthetic
registrar and the consultant surgeon not only did not think to use it, but both
say that they were not aware it was available. I find this perplexing and
surprising. I heard evidence which I accept that that availability of O
negative blood in the emergency department is a given Australia wide and it
would be expected that a senior surgeon and an anaesthetic registrar would
know at the very least of its availability, if not its precise location. I find
that both of those persons should have asked for it. I accept Professor
Maddern’s opinion that using the O negative blood may well have changed
the course of events.
27
The delay in blood
66. I find that this was caused by multiple factors. The main ones are the two
doctors making errors in filling out the form requesting a ‘group & hold’,
the failure by both surgeons and anaesthetists to check that the ‘group &
hold’ had in fact been done, and the underestimation of the risk of bleeding
leading up to the operation, if the risk had been realised then a ‘cross match’
would have been organised. Two lesser causes are the lack of a phone in
theatre and the failure of the laboratory to ring the theatre back when they
decided to reject the request, having been put on notice that blood was
needed urgently. I find that the laboratory has appropriately strict
guidelines and thus acted correctly both in refusing the two incorrectly filled
out requests and in refusing to send back the incorrectly labelled sample to
be signed. Mr Bittner gave evidence that had the blood been appropriately
‘group & held’, it would be available 15 minutes after a phone call from the
theatre.
67. I heard varying opinions on the importance of the delay in blood in causing
the death. I find that the importance of the delay was overestimated on the
day, but nonetheless that the delay was a contributing factor in this death. I
find that everyone was thinking that the blood was about to arrive at any
moment and had they been aware of the time it was actually going to take
they would probably have acted differently. However I also find that the
delay in blood would not have played a part had it occurred to any medical
staff to use the O negative blood which was provided for just such an
eventuality.
Inability to correctly fill in blood forms
68. Mr Bittner said that about 10% of forms are filled in incorrectly and that it
is a common thing for the laboratory to reject specimens and in fact it is a
form of education in itself. He said he thought the large error rate was
mainly due to the constant turnover of staff. He said there are doctors that
28
come up for four to six weeks at a time, from different hospital all over the
country, it is very hard to explain to them all how to fill in forms.
Difficulties in communication between the theatre and the pathology
laboratory
69. I find that the lack of phone in theatre, which meant that staff had to leave
the room to make a call, hindered communication between the theatre and
the laboratory.
70. In addition I find that the pathology laboratory could have been more
proactive in communicating the fact that they were not going to supply the
blood, given that they had been placed on notice that it was urgent. It is
unclear exactly what happened in the series of phone calls but I accept that
Nurse Jamieson had to keep ringing the laboratory to find out what was
occurring.
Lack of nursing support
71. There were an appropriate number of nurses working that Saturday to staff
one operation. However when the emergency intubation was required, some
nurses were needed to assist this and no additional nurses were called in,
resulting in insufficient nursing support.
The underestimation generally of the seriousness of the situation
72. I find that there was an underestimation generally by the surgical,
anaesthetic and nursing teams of the seriousness of the situation that was
unfolding and, in particular, of the amount of blood that had been lost. This
resulted in a failure generally to call for additional help as the situation
deteriorated, despite the fact that senior consultants were about 7 m away in
an adjacent theatre. I accept that it is not easy to estimate the amount of
blood lost, and to some extent it was guess work, but nonetheless on this day
it was significantly underestimated.
29
Lack of familiarity with local information
73. It became apparent that staff who had trained elsewhere, and had only been
at the Alice Springs Hospital for a short time, were unfamiliar with vital
information such as, variously, how to fill in a blood request, the
availability of O negative blood, the ease with which extra help was
available, the use of infusion pumps and how to put in arterial lines. I find
that a high turnover of staff at the Alice Springs Hospital is a reason for
this, and a particular problem for this hospital.
Lack of communication between staff
74. Communication could have been and should have been clearer between the
anaesthetist and the surgeons in theatre, and the failing was on both sides.
If it had been clearer then the seriousness of the situation may have become
apparent earlier. In addition there was a lack of communication amongst the
surgical team about the delaying of the operation from the Friday, the
decision appeared to have been made without talking to the consultant and
there was no documentation of the decision whatsoever.
Other factors
75. There were some additional, and less critical, factors. The code blue button
did not work, which is a matter of concern, although I find that this is
unlikely to have made a difference to the outcome on the day. The
anaesthetist had difficulties using the infusion pump. There was no rapid
infuser available in theatres.
Conclusions
76. Overall I find that there were too many errors to suggest that this was a
totally unexpected breakdown. It is apparent to me that as of April 2006
there were some serious systems and resource issues at the Alice Springs
30
Hospital that meant that this sort of a death was more likely to occur than it
should have been.
THE HOSPITAL RESPONSE
77. There were 6 recommendations made by Professor Maddern as part of his
report. In addition 8 recommendations were made arising out of the
internal hospital review processes. I have attached the 14 recommendations
as a table at Annexure A. I find that the recommendations were well
targeted at fixing the systems issues that caused this death, and I commend
Alice Springs Hospital for adopting Professor Maddern’s recommendations,
as well as coming up with 8 of their own, and for committing themselves to
implementing the bulk of them.
78. I heard evidence from various senior medical staff about what had been done
in their own areas, as well as evidence from Vicki Taylor, the General
Manager, about the hospital response overall. She provided me with a
Table, summarising the recommendations, the person responsible for their
implementation and what has happened (Exhibit 6) which was of great
assistance. I have listed in the table at Annexure A the steps that have been
taken to implement the recommendations.
79. I do not intend to make recommendations that cover the areas targeted by
the Hospital as they have already comprehensively been done.
80. Recommendation two has not been implemented. Dr Jacob said he was of
the opinion that the two forms should be kept separate. He said that giving
blood to a patient is an important decision and the separate forms highlight
the significance of it. Mr Bittner also did not agree with the
recommendation. He said if all the information currently on the two forms
was to be contained on one form it would have to be a two sided form,
which led to the risk of missing requests because the back of the form was
not looked at. In addition it is a Territory wide request form so would have
31
to be changed for the whole Territory. I accept that the risks of blood
transfusion warrant more stringent collection procedures and it is
appropriate to have a special form for this, and accept that this
recommendation need not be implemented.
81. Recommendation six has not been implemented fully and this highlights a
very significant problem which the Alice Springs Hospital has been unable
to permanently correct due to resourcing issues. I have found that the delay
in the operation was a significant contributor to this death. Professor
Maddern gave evidence that emergency operations being pushed out of
hours was a substantial problem. I accept the evidence of Dr Jacob that the
cause of the delay in this, and many other cases, is the lack of a designated
emergency theatre. He gave evidence that 70% of cases requiring surgery
are emergency cases, but they are currently mostly operated on in the
evening, on weekends, or slotted in between elective cases. He states that
this is suboptimal; firstly because of the reduced staff out of hours, and
secondly because the extensive delays result in patients either eating or
drinking while waiting, as in this case, or absconding. I also heard evidence
that delays are suboptimal in terms of medical outcomes.
82. In April 2006 when this death occurred there was no dedicated emergency
theatre, which meant that emergency cases were routinely delayed. Changes
since that time have resulted in a dedicated emergency theatre scheduled for
3 days a week. However I heard evidence that in most weeks at least one
day is cancelled, because if one nurse calls in sick then there are not enough
staff to run it. In addition the funding for this theatre was special funding
provided by the Acute Care Network to reduce the waiting time on the Alice
Springs Hospital elective waiting list. This funding ceases at the end of
2007. The statistics also show an increase in the number of surgical
admissions from 1428 in 2003 to 2472 in 2006. This is a very large number
of surgical admissions. Dr Jacob said this is because there is an enormous
amount of trauma in Alice Springs. There were of the order of 2800 trauma
32
cases in 2006 and I heard evidence that if there are more than 400 trauma
cases a year then a centre should be considered as a major trauma centre
according to the Royal Australasian College of Surgeons.
83. I heard evidence that a dedicated emergency theatre would cost about $5
million a year, taking into account operational costs, salaries and support.
84. I accept the evidence of Dr Jacob about the need for a dedicated emergency
theatre, which receives support from recommendation number 6 in Professor
Maddern’s report.
RECOMMENDATIONS
85. Sadly, and unfortunately, the death of the deceased in the Alice Springs
Hospital was preventable. In my view, the death occurred, inter alia,
because of a lack of resources for emergency surgery. Accordingly, I
recommend that the Northern Territory Government fund a dedicated
emergency theatre for the Alice Springs Hospital as a matter of priority.
Dated this 10th day of December 2007.
_________________________
GREG CAVANAGH
TERRITORY CORONER
33
ANNEXURE A
RECOMMENDATIONS IMPLEMENTATION
A. Arising from Professor
Maddern’s Report
1. Grouped and [cross]
matched blood when
requested should always be
checked as being available
prior to the commencement
of any surgical procedure.
This has been implemented.
Blood is cross matched before
any procedure where a major
vascular injury is suspected. A
recent audit showed that blood
had been grouped and held in all
cases, but cross matched in only
50% of cases. The head of
surgery reviewed this and
determined that it was appropriate
cross matching. If a request has
been made for blood to be ‘group
& held’, or cross matched, the
senior surgeon has responsibility
to check the pathology results and
ensure that it is available before
proceeding.
2. The Pathology Department
should consider the
formation of one form
suitable for blood
transfusion and general
blood requests rather than
having different forms for
different tasks.
This has not been implemented.
This is not supported by the
Pathology Department, and it
would require changing forms
across all sites in the Northern
Territory. Coroner accepts the
reasons behind not implementing
this form.
3. Anaesthetic Registrars must
be instructed of the
importance to call for
additional help at the
earliest possible time rather
than attempt to manage
situations for which two
anaesthetists would be
better than one.
This has been implemented. It is
included in a more formalized
orientation program that has been
introduced, and reiterated in the
regular education sessions held in
the department.
4. Nursing staff need to be
aware that if a second
theatre is opened a second
team need to be called in,
irrespective of the nature of
the procedure that is
thought to be conducted
This has not been implemented.
This is essentially because of
insufficient funding to support
this. There are insufficient funds
to establish a second on call team.
Instead the practice is for staff to
indicate availability over the
34
within the operating
theatre. It is better to over
staff on these occasions
rather than under staff.
weekends (a ‘shadow shift’) and
for a second team to be called as
required. Over a year a second
team was needed on three
occasions only and it worked
well.
5. Surgical Supervision should
be provided for all
inexperienced registrars.
The Alice Springs Hospital
should consider taking only
second year Advanced
Trainees for this rotation.
All cases going to theatre are now
seen by the consultant surgeon
before they go for surgery. Alice
Springs Hospital has requested
only second year trainees and it
has been confirmed from the
Alfred Hospital that this will
occur, this will start in 2008.
6. Additional emergency
surgical lists should be
provided during the week
and the rostering of nursing
staff across weekends needs
to be considered in the light
of safe working hours and
practice.
See discussion in findings.
B. Arising out of Internal
Hospital Processes
7. The senior surgeon will
review all surgical patients
before surgery. If it is
determined that a surgical
registrar will complete the
case, the senior surgeon
will be available for
supervision and assistance
at all times.
An audit of major vascular
surgery files showed that 50%
had documentation showing the
patient was reviewed by the
consultant. The Head of Surgery
considers that the actual
proportion of cases reviewed is
likely to be higher but is not
shown because of the lack of
documentation in files.
Discussions are taking place to
improve the documentation.
8. Code Blue button in theatre
to be serviced regularly and
theatre staff will be
educated in its use.
There is now a schedule of testing
for the Code Blue button.
9. A telephone will be placed
in all theatres to avoid the
need to leave the theatre in
an emergency.
Telephones have now been placed
in all theatres.
10. An in-service of the use of
the rapid infuser will be
A rapid infuser was delivered on
19 June 2007 and three training
35
held for all theatre staff.
Consideration will be given
to the purchase of a second
rapid infuser to be stored in
theatre.
sessions on how to operate it have
occurred since this time.
11. It is recommended that
theatre begin on time.
A review of starting times showed
around 62% of operations started
on time; this is something that the
Hospital is finding difficult to
improve on, it is being monitored
through a theatre management
group.
12. It is recommended that
there is an increase in ICU
beds. This will require
resources to increase staff.
This has not been implemented as
a review shows that this is not
needed.
13. It is essential that all
theatre staff, especially the
nursing staff, are
adequately trained and have
theatre certification.
Currently staff are
underqualified which
increases the risk for Alice
Springs Hospital. Training
is a priority.
By the end of 2007 8 staff will
have received their formal
qualifications which is close to
50% of all staff and up from 4
staff in 2006.
14. A patient with the same
first name was initially sent
to theatre.
A ‘right person, right site’ policy
is operating in theatre, and a
‘time out’ policy is operative.
There have been in services with
theatre nursing and posters placed
in each theatre above the scrub
sink outlining the 5 step
procedure. Recent investigations
show that the time outs are now
occurring 100% of the time.
There is a clinical nurse educator
in theatre who has taken this
aspect on.
36
Other areas of concern that
were not formal
recommendations
All surgical staff are now
oriented on the storage of O
negative blood in the Emergency
Department and procedures to call
for that blood.
All anaesthetic staff are now
oriented to the location of O
negative blood.
Haemaglobin level is to be
measured one hour before all
major vascular surgery and this is
to occur regardless of any delay
in scheduling surgery.
During orientation (3-6 months)
an anaesthetic registrar starts by
working with a supervising
colleague and proceeds to
progressively work on their won.
Until orientation is formally
completed all cases are discussed
with a supervising consultant
before commencement. There is
an orientation package in place
for Anaesthetic registrars and the
new head of Anaesthetics is
developing a manual for this.
Mandatory orientation program
for all new doctors which
includes, among many other
things, a presentation by the
pathology department on how to
fill in blood request forms. A
sheet of paper outlining all
required components will be
placed in the doctor’s personnel
file and each component will be
ticked off as it is done. The
orientation has to happen before
the doctor starts working in the
hospital.
Northern Territory Health in the
process of employing a
37
transfusion nurse whose
responsibility will be Territory –
wide education about general
transfusion procedures, including
the correct way to request
transfusion products.
