Record of Investigation into Death
Coroners Act 1995
Coroners Rules 1996
Rule 11
I, Rod Chandler, Coroner, having investigated the death of
Eileen Margaret Bryant
WITHOUT HOLDING AN INQUEST
Find that :
Eileen Margaret Bryant ("Mrs Bryant") died on 15 May 2007 at the Ouse District Hospital ("the ODH") at Ouse.
Mrs Bryant was born in New Norfolk on 23 December 1932 and was aged 74 years. She was a widow and retired.
I find that Mrs Bryant died from ischaemic heart disease. Contributing factors were combined drug (Amitriptyline and Tramadol) intoxication, emphysema, healing rib fractures and some pulmonary emboli.
At the time of her death Mrs Bryant was in the care of a medical practitioner at the ODH.
Circumstances Surrounding the Death :
Mrs Bryant lived on her own at Bothwell. She had three daughters who regularly visited and cared for her.
Mrs Bryant had a past medical history of severe rheumatoid arthritis, ischaemic heart disease, chronic obstructive airways disease and pernicious anaemia. She was prescribed Tramadol and Endep for pain relief, 50mg each, as required. Despite her chronic disabilities she kept in reasonable health.
On 7 May 2007 Mrs Bryant had an unwitnessed fall at her home. She sustained lacerations to her arms and an injury to her right chest wall, which was thought to be a rib fracture. Her General Practitioner, Dr Greg Booth advised Mrs Bryant to increase her Tramadol and to add Panadol for her chest pain.
Mrs Bryant had a review appointment with Dr Booth on 10 May 2007. On this occasion she reported that her chest was still painful and she had difficulty getting out of bed and chairs and using the toilet. However, she declined a hospital admission preferring to remain in her home.
On 14 May 2007 Mrs Bryant had a witnessed fall at home whilst attempting to get out of a chair. She again saw Dr Booth. She had not been eating or drinking well. Dr Booth believed that she was unable to care for herself and arranged for her transfer to the ODH for supportive therapy.
By 4.15pm on 14 May Mrs Bryant had arrived at the ODH. She was briefly seen by Dr Renier Swart who advised her that arrangements would be made for chest x rays and for her referral to a physiotherapist.
At 8.30 pm that evening nursing staff checked on Mrs Bryant. She was noted to have shortness of breath, her oxygen saturation reading was 86% on room air and her temperature was 37º. Supplemental oxygen was started with nasal prongs and saturation improved to 95%.
At about 1.00am on 15 May 2007 Mrs Bryant was unsettled and was experiencing increased pain on her right side, worse on inspiration. She was short of breath on minimal exertion. Her oxygen saturation was 96% on 2 litres per minute of oxygen. She had oedema of both lower legs. Oral analgesia was administered. Her heart rate was 79 per minute, respiratory rate was 32 per minute and blood pressure was 113/80. Mrs Bryant was moved into a ‘Jason Recliner’ style chair next to her bed where she settled, falling asleep and snoring loudly.
At about 4.30am nursing staff noticed a pause in Mrs Bryant’s snoring. They attended and found her to be in cardiac arrest. An ambulance was called, the time of the call being recorded at 4.33am. Meantime, nursing staff maintained cardio pulmonary resuscitation.
The ambulance crew arrived at the ODH at 5.27am. Mrs Bryant’s heart had stopped contracting and her pupils were fixed and dilated. Resuscitation was ceased and Mrs Bryant was declared deceased.
A post-mortem examination was undertaken by State Forensic Pathologist, Dr Christopher Lawrence. Toxicology tests revealed ‘Potential toxicity and drug interaction due to greater than therapeutic concentrations of amtriptyline and tramadol.’ Dr Lawrence noted that ‘It is difficult to evaluate the relative significance of these drug levels and their interactions given the heart disease and emphysema.’ In Dr Lawrence’s opinion the cause of Mrs Bryant’s death was ischaemic heart disease. It was his further opinion that combined drug (Amitriptyline & Tramadol) intoxication, emphysema, healing rib fractures and small pulmonary emboli were probable contributing factors.
It was determined by the Aged Rural and Community Health Clinical Management Committee that the circumstances of Mrs Bryant’s death be reviewed. The following were noted as issues of concern:
"1. No admission letter or documentation was on file as to the assessment diagnosis or care provided by the Patient’s GP.
2. No patient physical assessment was documented by the admitting (medical) or nursing staff. No clear medical care plan was recorded.
3. No past medical history was documented by either the admitting (medical) or nursing staff.
4. There was no evidence to suggest that previous medical notes were requested for review by the nurses, on the admission of this patient.
5. No falls risk assessment was done on admission despite 2 recent falls at home.
6. The admission observations recorded by the nursing staff at 1630 were not complete and those taken were not within normal parameters. There is no evidence that the (doctor) reviewed these or was advised of this by the nursing staff.
7. The admission observations provided early evidence that the patient’s condition was not stable. Temperature 37.8 per axilla, respirations 28, pulse 92, BP 100/50. Oxygen saturation was not recorded, admission weight and urinalysis were not recorded.
8. Regular observations were not commenced in response to the above i.e. the patient’s condition was not monitored by nursing staff.
9. At 2040 it was noted that the patient was short of breath and the Oxygen saturation was recorded as 86% and oxygen was commenced – it is not clear as to how long this was continued. There is no evidence that the (doctor) was advised of this observation. No regular observations were commenced to monitor the patient’s condition.
10. At 0100 the patient was noted as having right sided chest pain with respiratory rate of 32 and BP 113/80. No evidence that (the doctor) was notified or Oxygen saturation levels checked.
11. During the night shift the Patient was noted as having Shortness of breath so was removed from bed to sitting upright in chair to sleep.
12. At 0430 patient noted to not be breathing, removed from the chair to the floor and CPR commenced and ambulance called. No record of CPR activity on file i.e. what equipment used, attempts to record observations of client.
13. A "strip" from a heart monitor was found in the file with time stamp showing "0540" and also recording "low battery."
14. The ambulance was called at 0430 and arrived at 0530, ambulance officers assessed patient as deceased at 0530. It is not clear why the delay in what must have been identified as an urgent case.
15. The medication chart identified 9 medications for this client. During the admission the patient was administered the following medication as per the medication chart. Paracetamol 1 gram at 2030, Endep 50mg 2030, tramadol 50mg at 1830 and 0045. The patient was also taking Uremide 40 mg daily, Aspirin 100mg mane, Ramipril 10 mg mane, Omeprazole 20 mg mane, Tramadol 50 mg, 6/24, Panadol prn, Diazepam 5 mg ½ tablet prn."
The review of Mrs Bryant’s death was undertaken by Ms Gina Butler, the Director of Nursing for Aged Rural and Community Health and by Dr George Cerchez, the Senior Medical Advisor for Primary Health. That review led to multiple recommendations being made including the following:
"1. That the Senior Medical Advisor contact (Dr Booth and Dr Swart) and discuss the findings noted.
2. The Senior Medical Advisor contact Tasmania Ambulance Service to review the ambulance response in this incident.
3. (Ms Butler) discusses the findings noted and following recommendations with the nursing staff at the site as soon as practicable.
4. That all inpatients will have a full set of admission observations, (T,P,R,BP, Oxygen saturation), weight and urinalysis recorded. Observations will be four hourly for the first 24 hours before being reduced if within normal range.
5. That all inpatients will have a full nursing history and assessment completed on admission.
6. That the client Risk Assessment forms will be implemented on site following training provided by the CNE.
7. The CNE and Site Manager review the emergency response equipment and checking systems to ensure equipment is ready and fit for use at all times.
8. Clinical Handover education session to be provided by CNE to staff using the clinical Handover audit tool as basis for education provided.
9. The site manager will review the (medical) and Nursing team communication and establish monthly joint (medical) and nursing meetings (minuted) to discuss clinical care issues and audit findings.
10. That clinical supervision of inpatient care will be reinforced to include Site Manager attending handover in afternoons, Review of inpatient files at least weekly by the site manager, Client records review audit on discharge.
11. The CNE will conduct client file review, medication audit and clinical handover audit fortnightly (with site staff) and report back findings to Site Manager.
12. Site Manager will report back to operational management and CMC monthly re progress on recommendations and result form audits."
Dr Cerchez also undertook a review of Mrs Bryant’s prescription of Tramadol and Amitriptyline. He reports that her prescription of Tramadol for pain relief was ‘at a reasonably low dose of 50mg tablet at night. It was a long term medication and the frequency of prescriptions as per record (enclosed) would support this assertion. The prescription was labelled take 4 times daily’. Dr Cerchez further reports that the Amitripyline prescription history does not indicate excessive prescription of this drug. Finally he notes that Mrs Bryant’s drug chart at the ODH indicates that two tablets of Tramadol were administered to Mrs Bryant within a seven hour interval. Only one tablet of Amitriptyline was administered.
Dr Cerchez has concluded from his review that the possible explanation for the recorded greater-than-therapeutic concentrations of amitriptyline and tramadol "would appear that (Mrs Bryant) increased her dose of pain relieving medication (tramadol) to significant levels when she fell and fractured her ribs one week prior to admission." Inadequate hydration at home may have also contributed to the elevated levels.
Clinical Professor Anthony Bell, Chief Medical Officer at the Royal Hobart Hospital has conducted a review of Mrs Bryant’s death. Clinical Professor Bell noted that the events leading up to her death were ‘complex.’ He provides this opinion as to the most logical course of events:
"1. Mrs Bryant’s heart was abnormal. Her long standing hypertension had caused left ventricular hypertrophy. The right ventricle was also hypertrophic. The heart (left ventricle) was dilating, a mechanism of compensation for decreasing heart function. The heart microscopically showed evidence of injury. There was mild coronary artery disease. These changes are associated with an increased risk of sudden death.
2. The Post Mortem showed fractures of ribs 1-6 antero-laterally on the right side, consistent with the original fall. The injury is significantly more extensive than expected from the tone in Dr Booth’s notes, certainly more that I expected reading the clinical course. This may relate more to osteoporosis rather than a greater traumatic injury.
3. The right lung is nearly double the weight of the left lung – bronchopneumonia is listed in the pathological diagnosis and consolidation of the lower lobe of the right lung described. This is due to the fractured ribs causing pain, decreasing cough with retention of secretions and onset of pneumonia. The low oxygen levels noted are caused by pneumonia.
4. The kidneys show hypertensive damage showing the long standing hypertension was causing significant organ damage.
5. The blood level of amitriptyline was elevated. This drug causes cardiac release of adrenaline and is associated with risk of cardiac arrest in the overdose situation, and possible in this case.
The sequence of events is thus:
1. Fall with significant right sided rib fractures
2. Pneumonia secondary to rib fractures
3. Lowered blood oxygen due to pneumonia
4. Heart stress due to trauma and low oxygen
5. Elevated amitriptyline levels may play a role
6. Sudden cardiac death due to above factors on the basis of pre-existing cardiac disease."
Ambulance's Delayed Response :
I have noted above that a call for an ambulance was made by nursing staff at the ODH at 4.33am yet an ambulance crew did not arrive until 5.27am. An explanation for this delayed response was sought from the Tasmania Ambulance Service ("TAS").
Superintendent Andrew O’Brien of TAS has reported that normally an ambulance crew at New Norfolk or Bridgewater will comprise a salaried paramedic and one volunteer ambulance officer. However, at the time of the call from the ODH neither crew had a volunteer to assist. A decision was made for both the New Norfolk and Bridgewater units to meet at the New Norfolk Station and for them to respond together. This decision meant that the departure of an ambulance from New Norfolk was delayed by about 20 minutes.
Superintendent O’Brien has acknowledged that the response time was ‘longer than normally would be expected when responding from New Norfolk to Ouse. The decision to delay the response until Bridgewater had arrived at New Norfolk Station was not within the standard operating procedure. This procedure requires that for emergency cases the nearest available crew is despatched immediately and the crew travel without delay to the incident.’
Superintendent O’Brien has further advised; "The service will have further discussion with the staff involved to ensure the likelihood of future similar events is minimised."
Findings, Comments and Recommendations :
I am satisfied that a thorough and detailed investigation has been carried out into the death of Mrs Bryant and that there are no suspicious circumstances.
Dr Lawrence’s opinion upon the cause of death and its likely contributory factors is largely consistent with those opinions of Clinical Professor Bell and in particular his view upon the likely sequence of events. I am therefore satisfied that Mrs Bryant died as a result of ischaemic heart disease with combined drug (Amitriptyline and Tramadol) intoxication, emphysema, healing rib fractures and some pulmonary emboli being contributory factors.
The circumstances surrounding Mrs Bryant’s admission to the ODH and the care and management received by her in that facility raise many matters of concern. These have been identified in the review ordered by the Aged Rural and Community Health Clinical Management Committee and the recommendations made following that review are in my opinion comprehensive and appropriate. I am aware that the ODH has been closed since Mrs Bryant’s death. Nevertheless, the recommendations arising from the review of her death do in large part have application to all similar rural health facilities and I would recommend their universal adoption as appropriate.
The time taken by TAS to attend the ODH was far longer than was reasonable and was, it seems a direct consequence of a failure to comply with TAS’s standard operating procedures. The genesis for that failure was a shortage of volunteer personnel at New Norfolk to complete an ambulance crew. This is a matter for real concern. It is my recommendation that TAS takes steps to review its manning arrangements to ensure that the difficulty which presented on 15 May 2007 does not recur. I have noted above that the ambulance was delayed by about 20 minutes in attending at the ODH. However, in the circumstances of this matter, it is in my opinion unlikely that Mrs Bryant’s death would have been avoided if the ambulance had attended within a more reasonable time.
Combined drug intoxication has been identified as a factor contributing to Mrs Bryant’s death. The reason for the greater-than-therapeutic levels of both Tramadol and amitriptyline in Mrs Bryant’s blood is not apparent on the evidence although the explanations provided by Dr Cerchez may have some validity. However, the evidence overall is not sufficient for me to make positive findings on this subject.
I conclude by extending my sincere condolences to Mrs Bryant’s family.
Dated Monday 1 November 2010 at Hobart in Tasmania.