RECORD OF INVESTIGATION INTO DEATH (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Robert Pearce, Coroner, having investigated the death of
Nita Joan Jenkins
WITHOUT HOLDING AN INQUEST
(a) The identity of the deceased person is Nita Joan Jenkins, born 15 March 1938;
(b) Mrs Jenkins died on 23 September 2010 at 104 Abels Hill Road, St Leonards in Tasmania;
(c) The cause of Mrs Jenkins’ death is ischaemic heart disease causing ventricular fibrillation;
(d) No other person contributed to the cause of Mrs Jenkins’ death.
1. At the time of her death Nita Joan Jenkins was aged 72. She lived at 3 Anson Street, Waverley. Her husband died some years earlier. She had two children including a daughter Julie-Anne Bauld. Mrs Jenkins occasionally stayed at Mrs Bauld’s house at St Leonards.
2. On 22 September 2010 Mrs Jenkins phoned her daughter to say that she was not feeling well. An ambulance was called and Mrs Jenkins was taken to the Emergency Department of the Launceston General Hospital. She complained of shortness of breath, feeling faint, dizziness and palpitations. The Ambulance Tasmania officers noted her heart rate was elevated at about 160-170 beats per minute.
3. Mrs Jenkins was admitted to the Emergency Department about 30 minutes after her arrival. She was assessed by Dr Pascal Gelperowicz, a locum emergency physician in the position of staff specialist in the emergency department. An electro-cardiogram was noted by Dr Gelperowicz to show atrial fibrillation with a rapid ventricular rate. A blood test disclosed an elevated troponin level of 0.048.
4. An attempt to treat Mrs Jenkins’ atrial fibrillation by drug therapy, the administration of doses of the beta blocker Metoprolol and magnesium infusion was not successful. As a result direct current cardioversion (DCR) was applied under sedation using 100 joules as a single shock. The procedure reverted Mrs Jenkins back to normal sinus rhythm. Following the DCR Dr Gelperowicz noted a 10 second period where the heart monitoring showed a broad complex tachycardia. A post DCR electro-cardiogram demonstrated a new anterior T-wave inversion.
5. Dr Gelperowicz reports that at about 11.00 pm he requested that Mrs Jenkins be admitted to the hospital for ongoing monitoring and a repeat troponin test. Dr Gelperowicz’s shift finished not long afterwards.
6. Subsequently Mrs Jenkins was assessed by a medical registrar, Dr Sudhakar Vemula. Dr Vemula formed the view that Mrs Jenkins should be discharged from hospital. He based his opinion on her history and symptoms, the ECG findings and “cardiac enzymes” and concluded that he had “no reason to believe that she had an acute ischaemic event” He referred in particular to the absence of chest pain throughout Mrs Jenkins’ presentation and that her symptoms were consistent with “chronic atrial fibrillation”. No further troponin test was undertaken. He arranged for her to be seen at the cardiology out-patient clinic.
7. Thus, at about midnight on 22 September 2010 Mrs Bauld was phoned by the hospital to come and pick her mother up. It took her some time to organise an appropriate vehicle and she did not arrive until about 2.30 am on 23 September. She took her mother to Mrs Bauld’s home at St Leonards and they arrived at about 3.00 am.
8. Mrs Jenkins went to bed. Mrs Bauld checked her an hour or two later and found her to be unresponsive. She attempted CPR and called an ambulance. All further attempts at resuscitation were not successful and Mrs Jenkins died.
9. The coronial investigation of Mrs Jenkins’ death has included, amongst other things:
(a) a post mortem examination conducted by Forensic Pathologist Dr Ruchira Fernando;
(b) review of the post mortem examination by the State Forensic Pathologist Dr Christopher Lawrence;
(c) reports from Dr Gelperowicz, Dr Vemula and the Director of Medicine at the LGH Dr Alasdair McDonald;
(d) review of the records of the Launceston General Hospital (“the LGH”);
(e) a report from emergency medicine consultant Dr John Vinen, former Emergency Medicine Department Head at Royal North Shore Hospital, Sydney NSW;
(f) advice in conference from a senior nurse investigator engaged by the Coronial Division and Dr Lawrence;
(g) a review of the evidence by Clinical Professor Anthony Bell.
10. In addition I have an affidavit from Mrs Bauld giving background information about her mother and outlining concerns she has about her mother’s treatment.
11. Based on all the evidence available to me I am satisfied that Mrs Jenkins died of ischaemic heart disease causing ventricular fibrillation leading to permanent cessation of her heart’s electrical activity. I have made a recommendation below concerning the decision to discharge Mrs Jenkins from hospital. Differences of opinion exist about the decision. It is impossible to determine whether, had Mrs Jenkins been admitted to hospital as Dr Gelperowicz recommended, it would have affected the outcome, but at least Mrs Jenkins would have been closely monitored.
12. By s28 of the Coroners Act a coroner investigating a death is required to find, if possible, when and where the person died, how the death occurred, the cause of death and to identify any person who contributed to the cause of death. It is proper that an investigation should identify not only the direct means or mechanism of death but also the circumstances attending the death.
13. The primary focus of an investigation is to seek out and record the facts concerning the death of a person. It is a fact finding exercise of an inquisitorial nature. The facts which are relevant are those which may enable findings about the matters the Act requires the coroner to, if possible, determine. It is not the function of an inquest to attribute any moral or legal responsibility or liability for a death or to hint at blame. It is not a means of apportioning guilt. A coroner is to determine facts. The facts, once determined, will speak for themselves and it is for others to, if necessary, draw legal conclusions.
14. In the course of the investigation Mrs Bauld raised some concerns about the decision to discharge her mother from hospital. Her concern is natural and understandable. However, I am not satisfied that the correctness or otherwise of the decision to discharge Mrs Jenkins’ affects any of the findings I am required, as coroner, to make. I am not satisfied that the decision maker “contributed to the cause of Mrs Jenkins’ death” within the meaning of that phrase in the Coroners Act. As I have attempted to explain, the coroner’s function is not to respond to professional or vocational failures in individual cases.
15. It is open to Mrs Bauld to raise that or other issues concerning her mother’s care in another forum if she wishes to do so.
16. I have decided not to hold in inquest into Mrs Jenkins’ death. The investigation has sufficiently disclosed the identity of the deceased person, the time, place, the relevant circumstances concerning her death and the particulars needed to register her death under the Births, Deaths and Marriages Registration Act. No other a person contributed to the cause of Mrs Jenkins’ death within the meaning of that term in the Coroners Act 1995. I do not consider that an inquest is likely to elicit any further significant and relevant information concerning the issues that I am required to determine.
17. In this case a patient was discharged by a medical registrar in the emergency department without reference to or contact with the staff specialist consultant who had recommended admission to a coronary care unit. I would recommend consideration and implementation of a system whereby patients referred by the emergency department to another medical practitioner for admission to hospital should not be discharged without reference to or discussion with the referring practitioner and a consultant.
I convey my sincere condolences to Mrs Jenkin's Family.
Dated: 6 day of March, 2013.