Record of Investigation Into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11 

I, Rod Chandler, Coroner, having investigated the death of 

Jeffrey David LIMBRICK 

WITHOUT HOLDING AN INQUEST

Find That : 

Jeffrey David Limbrick (‘Mr Limbrick’) died on 31 July 2007 at the Royal Hobart Hospital (‘the RHH’) Liverpool Street, in Hobart.  

Mr Limbrick was born in Hobart on 12 September 1943 and was aged 63 years.  He was married and a retired disability pensioner at the time of his death. 

I find that Mr Limbrick died as a result of complications from a thoracic spinal fracture. 

At the time of his death Mr Limbrick was in the care of medical practitioners at the RHH. 

Circumstances Surrounding the Death :

Mr Limbrick had for many years been suffering from ankylosing spondylitis, first diagnosed in 1988.  He had surgery in 2001 to stabilise his back.  In recent times Mr Limbrick had been treating this condition with hydrotherapy and pain relieving medication.  

On the morning of 2 July 2007, Mr Limbrick suffered a fall at home.  His wife heard his fall and then his call for assistance.  She found him lying on his left side in the passage way.  She covered him with a blanket and called an ambulance.  

Mr Limbrick was conveyed to the NWRH where a plain spinal x-ray detected no new fracture.  Blood samples were taken for testing.  He was then given an analgesic for pain relief and discharged home. 

For the remainder of that day Mr Limbrick was in considerable pain which effectively rendered him immobile.  On the morning of 3 July Mrs Limbrick again summoned an ambulance.  Her husband was returned to the NWRH.  A CT-scan of the thoracic spine was then undertaken.  It identified an unstable fracture of T5 – T6 without compression or protrusion into the spinal canal.  Mr Limbrick was then admitted into the care of an Orthopaedic Surgeon.  His usual aspirin medications were ceased.  Mr Limbrick’s condition was discussed with the Neurosurgical Unit at the RHH and the following day he was transferred to the RHH where he was admitted under the care of Neurosurgeon, Mr Arvind Dubey.  It was decided to manage Mr Limbrick conservatively.  He was fitted with a Minerva thoracic lumbar brace and a gradual ambulation process was commenced.  It was also decided to arrange an MRI scan to determine the status of the thoracic ligaments in the area of the fractures.  He was commenced on heparin and aspirin as a precaution against leg clots and pulmonary embolism.  

In the evening of 5 July 2008, Mr Limbrick experienced difficulties breathing.  His brace was removed.  Later that night Mr Limbrick reported reduced sensations as well as reduced power from the waist down.  He was reviewed by Neurosurgical Registrar, Dr Eftekhar at about 1:30am and diagnosed to have a sensory deficit around the mid-chest corresponding with the T5-T6 area.  He also did not have any movement in his lower limbs.  Too, he required urinary catheterisation and had reduced anal tone.  

Mr Dubey ordered an urgent MRI to ascertain the reason for the sudden neurological deterioration.  However, because of Mr Limbrick’s abnormal spine curvature, an MRI was unable to be conducted at that time.  A CT scan was undertaken instead.  It disclosed no evidence of any blood clotting but mild spinal canal narrowing at T5 and T6 was evident secondary to slight protrusion of fracture fragments.  It was also noted at the time that Mr Limbrick did have some abnormal coagulation parameters with an INR of 1.8, an APTT of 34 and a platelet count of 61,000.  Mr Dubey ordered an urgent CT myelogram.  He also terminated the heparin and aspirin medications.    

The following morning, Mr Dubey again examined Mr Limbrick and found him to have weakness in the legs.  It was planned to treat him with cryoprecipitate, fresh frozen plasma and platelets to correct his abnormal coagulopathy. He was also treated at this time for hypertension and a low urinary output.  

An MRI was able to be performed on Mr Limbrick in the mid-afternoon of 8 July with him being scanned on his side using a surface coil.  It disclosed a long extradural haematoma extending from T5/6 to T9/10 and was reported to be “occupying the major part of the spinal canal and causing severe cord compression.”  After discussion with his family Mr Limbrick was taken urgently to theatre where Neurosurgeon, Dr Pauline Waites carried out a decompressive laminectomy at the T6/T7 levels and evacuated the extradural haematoma.  Mr Limbrick was then admitted to the Intensive Care Unit.  

Post-operatively, Mr Limbrick’s paraplegia did not significantly improve.  It was also complicated by pneumonia and ongoing coagulation difficulties.  Eventually, after discussion with family members it was decided to treat Mr Limbrick palliatively.  He died in the RHH on  31 July 2007.  

Investigations/Reviews : 

A post-mortem examination was conducted by State Forensic Pathologist, Dr Christopher Lawrence.  It was the opinion of Dr Lawrence that Mr Limbrick had died as a consequence of complications from his thoracic spinal fracture.  He considered that significant contributing factors to his death were the ankylosing spondylitis and cirrhosis of the liver.   

Clinical Professor Anthony Bell is the RHH’s Chief Medical Officer.  He conducted a review of Mr Limbrick’s hospital care and treatment which he has detailed in a comprehensive report.  In that document Clinical Professor Bell makes these comments: 

  •  “Mr Limbrick was at high risk of spinal fracture after the fall at home. The history of ankylosing spondylitis for over 20 years, the spinal deformities (scoliosis) and previous spinal surgery indicate a high risk. The noted fusion of the bones of the spinal column means that a new fracture is virtually impossible to be seen on a plain x-ray. Secondly that a fracture is the only site where the spine moves thus the patient is at great risk of spinal cord injury, and it is difficult to stabilise the injury. Therefore the appropriate action would have been a CT scan at the area of pain and tenderness. Observation overnight with spinal precautions, with a CT scan in the morning is a reasonable course of action.”

  •  “The second issue is that blood tests were carried out but there is no record of review of the tests at NWRH, either in ED or on the ward. There is no indication in the Patient Transfer Nursing (notes) that blood test results were sent to the RHH.  There is no record that the blood test results were reviewed at the RHH. The blood test results entered the RHH digital medical record system three days after Mr Limbrick's arrival at the RHH.”

  •  “The failure to review the blood results, has meant that Mr Limbrick's liver disease was not discovered until after the epidural bleed that caused the paraplegia. The liver function tests (LFT of 2 July 2007) revealed jaundice, high gamma GT and ALP and a low albumin. Mr Limbrick's LFT's had been abnormal for at least three years on the cumulative result sheet. There is no evidence in the medical record from NWRH of attempts to investigate the liver dysfunction. The full blood count obtained on 2 July revealed a low platelet count, platelets are the blood cells that are activated to clump and form clots when stimulated.”

  •  “The liver dysfunction is highly likely to be associated with blood coagulation defects. This occurs either through clotting factor deficiency or vitamin K deficiency. This failure to note the blood test results lead to the erroneous assumption that the patient had normal coagulation.”

  •  “The admission notes are a focussed admission about the spinal column injury. There is no comprehensive medical admission. Of specific interest would have been a history regarding alcohol consumption, drug history and an examination of the major organ systems. There is no determination of the presence of chronic liver dysfunction by standard clinical examination. There were no blood tests ordered (or chest X-Ray, electrocardiogram etc) and this omission is not explained. The standard of practice is for all patients admitted to the ward beds to receive a complete medical history and examination, and investigations as required. In a male aged over 60 years usual blood tests should have been done.”

  •  “On 5 July 2007, Mr Limbrick was reviewed by the Neurosurgical Registrars. An MRI scan was to be organised and a back brace fitted. There is no evidence of review by the Consultant Medical Staff.

I would have expected Consultant review within 24 hours of admission. There was no formal requirement at that time in the Division of Surgery requiring Consultant review within 24 hours.”

  •  “The development of back pain, inability to breathe and a wish to have the brace removed indicate a problem occurring with the fitting of the brace or spontaneously coincidentally. Medical review was indicated at that time.  As stated above the patient in Mr Limbrick's position with a high risk of spinal cord injury and the difficulties associated with stabilisation of the spine(and) the onset of new pain associated with breathing problems should have triggered a call for medical review. I note that there were no instructions in the admission note or the notes from the registrar rounds as to any special concerns that the medical staff may have passed on to the nurses caring for Mr Limbrick.”

  •  “The epidural bleed led to surgery to decompress the spinal cord and try and prevent permanent paraplegia. The surgical stress led to further liver decompensation and the liver decompensation led to Mr Limbrick's death, a not unexpected result in the presence of liver dysfunction.

The failure to recognise the liver dysfunction, coagulation problem and low platelet count led to a failure to correct the coagulation and platelet deficits. Therefore the patient bled and developed paraplegia, thus required the surgery that led to a high risk of death. Had the coagulation defect been corrected then the risk of bleeding is less and the chance of recovery higher.”

  •  “It should be made clear that even if the bleed had not occurred there was considerable risk that surgery to stabilise the spine would have been necessary at a later date due to failure to heal the fractures in this specific set of circumstances.”

  •  “Patients with coagulation disorders, I believe, should not receive the anticoagulant heparin and antiplatelet agent aspirin to prevent deep venous thrombosis. Mr Limbrick was fully anticoagulated in terms of the therapeutic range for treatment of pulmonary embolism with the anticoagulant drug warfarin. The dose of heparin was low and I believe made little if any difference in the case. Mr Limbrick was already on aspirin, then stopped then restarted. The effect of aspirin on platelet function is long after a single dose and I do not believe that the restarting of aspirin made any difference to the clinical course.”

  •  “The major determinant in this case was the liver dysfunction. There is insufficient information in the medical record to determine the cause of the liver dysfunction. Post mortem liver biopsy would have been helpful, but there was a chance the liver would be scarred beyond diagnosis.”

  •  “There was, in my opinion no attempt by the transferring Hospital, NWRH, to discover the cause of the liver failure. Alcohol is the most common cause of liver failure in Australia. There was a single reference to alcohol consumption (3 stubbies a day) and one note that states without evidence "not due to alcohol". There is a long standing elevation of the gamma GT suggesting alcohol, and on the single occasion when done the AST/ALT ratio was over I, suggesting alcohol as the cause.”

 
The circumstances of Mr Limbrick’s death were also the subject of an investigation by a Serious Incident Panel convened by the RHH.  That investigation led to the following recommendations: 

  1. That the RHH Neurosurgical Unit review and formalise its transfer process for patients who are transferred from the north of the State; and
  2. The transfer process be modelled similar to the system in place within the RHH’s Department of Plastics and Reconstructive Surgery.

Separate to the review undertaken by the Serious Incident Panel the RHH’s Division of Surgery reconsidered its practice concerning consultant review following admission.  That reconsideration has led to the imposition of a formal requirement within the Division of Surgery that consultant review take place within 24 hours of a patient’s admission to the ward. 

Findings and Comments :

I am satisfied that a thorough investigation has taken place into the death of Mr Limbrick and that there are no suspicious circumstances.   

I accept the opinion of Dr Lawrence and find that Mr Limbrick died as a result of complications from a thoracic spinal fracture.  I further accept that factors significantly contributing to the death were ankylosing spondylitis and cirrhosis of the liver.  

My investigation of the circumstances surrounding Mr Limbrick’s death has been very greatly assisted by the report of Clinical Professor Bell.  It identifies shortcomings on the part of both the NWRH and the RHH in the care and treatment of Mr Limbrick.  I adopt and accept Clinical Professor Bell’s comments upon each of these matters. 

It is a matter of particular concern that Mr Limbrick’s liver dysfunction was not detected at an earlier stage.  As has been noted the NWRH tested Mr Limbrick’s blood at the time of his first presentation but it seems that the results of those tests were not reviewed by medical staff at the NWRH nor were they conveyed to the RHH at the time of Mr Limbrick’s transfer.  Had those results been considered by medical staff it should have been apparent that Mr Limbrick was suffering from liver disease and that it would be inappropriate to manage him on the basis that he had normal coagulation.  It should also have been apparent that corrective steps needed to be taken to correct the coagulation defect.  Had Mr Limbrick been managed in this way it is likely that he would not have suffered his epidural bleed and resultant paraplegia which made necessary the urgent spinal surgery.  If the urgent surgery had not become necessary it is likely that Mr Limbrick’s death would have been avoided.  

I note and support the recommendations arising from the reviews undertaken by the Serious Incident Panel and the Division of Surgery.  It is in particular hoped that the RHH now has in place a transfer process which guarantees the timely and comprehensive provision of all relevant patient information by all regional hospitals so that the risk of similar tragic outcomes can be minimised.  

I conclude by conveying my sincere condolences to the family of Mr Limbrick. 

DATED :  24 August 2011 at Hobart in the State of Tasmania. 

 

Rod Chandler
CORONER