RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
I, Robert Pearce, Coroner, have investigated the death of
James Stirling McKinlay
(a) The identity of the deceased person is James Stirling McKinlay, born 1 March 1949, late of 7 Browne Street, Hadspen in Tasmania;
(b) Mr McKinlay died on 17 July 2012 at the Launceston General Hospital;
(c) Mr McKinlay’s death occurred as a result of a disseminated fungal infection, Rhizopus Microsporus, following major abdominal surgery on 15 May 2012 for cancer of the bile duct;
(d) No other person contributed to Mr McKinlay’s death.
1. In February 2012 Mr James McKinlay, then aged 63, presented at the Launceston General Hospital with obstructive jaundice. The cause of the condition was found to be cholangiocarcinoma (cancer) of the bile duct. For such a condition the only prospect of cure is major surgery which was undertaken on 15 May 2012. Mr McKinlay died on 17 July 2012 as a result of contraction of the fungus Rhizopus Microsporus, an organism which is invariably fatal in infiltrating major organs of debilitated patients, as was the case for Mr McKinlay. As a result of the coronial investigation described later in this finding, I have concluded that Mr McKinlay was treated with skill and care and that he died from complications following very major surgery.
2. The issue which led to and has been the subject of the coronial investigation concerns retention of a surgical pack in Mr McKinlay’s abdomen for a period longer than normally would be appropriate. The circumstances of that issue are set out below.
3. On Tuesday 15 May 2012 Mr McKinlay underwent a pancreatico duodenectomy, called a Whipples procedure. The surgery is difficult and complicated and lasted 10 hours. Commencing on the day after the surgery Mr McKinlay experienced ongoing problems with multiple episodes of internal bleeding. Between that day and 1 June 2012 he underwent numerous surgeries to attempt to address the problems, without success. During this period he suffered two cardiac arrests but was revived. He received massive blood transfusions.
4. Mr McKinlay underwent further surgery on 2 June 2012. Then operating room nurse’s report records that six small packs and one large pack were left in situ. It also records that 40 packs were used and the final count of packs removed is 33. The operation report to be completed by medical staff leaves blank the section for the recording of drains and packs. The surgical packs were deliberately left in Mr McKinlay’s abdomen at the site of the abdominal haemorrhage. Such a measure is sometimes undertaken in an emergency situation as a means of applying direct pressure to intra-abdominal bleeding that cannot otherwise be safely controlled. Usually packs are removed after two to three days otherwise they may become a potential source of infection.
5. Later on 2 June 2012, following the surgery, Mr McKinlay was transferred to the Royal Hobart Hospital, accompanied by his medical records and notes. The initial purpose of the transfer was for radiological intervention not available in Launceston. Surgery was undertaken by Professor Turner in Hobart on 4 June 2012. In the initial surgery some discolouration of the liver was noticed. Professor Turner performed further surgery on 11 June 2012. Between then and 14 June 2012 Mr Turner became aware of the possible retention of one surgical pack in Mr McKinlay’s abdomen. During another surgical procedure on 14 June 2012 a tightly compressed pack was discovered away from the site of the other packs and was removed.
6. A CT scan performed at the Royal Hobart Hospital on 2 June 2012 shows multiple packs in Mr McKinlay’s abdominal cavity including a single pack deeper and to the right hand side of the abdomen. It was not specifically commented on in the radiologist’s report. The operative notes from the Launceston General Hospital described seven packs used to pack Mr McKinlay’s abdomen prior to transport. During the surgery at Royal Hobart Hospital on 4 June 2012 six packs were removed. A plain x-ray taken on 6 June 2012 shows the retained pack but it was not reported by the radiologist reading the film or seen by the managing doctors. A CT scan of the abdomen on 7 June again shows the retained pack which was not noted.
7. On 18 June 2012 Professor Turner performed a re-look laparotomy. By that time some areas of necrotic liver had developed. By 20 June pathology tests confirmed the presence of Rhizopus Microsporus.
8. Because the organisim is invariably fatal in such circumstances Mr McKinlay was transferred back to the Launceston General Hospital for palliative care in proximity to his family and he died on Tuesday 17 July 2012.
9. The coronial investigation has involved careful examination of the medical records of the Launceston General Hospital and the Royal Hobart Hospital. A report was obtained from Professor Turner. Mr McKinlay’s treatment has been considered in conference with a panel comprising Dr Christopher Lawrence the State Forensic Pathologist, Pathologist Donald Ritchie, Clinical Professor Anthony J Bell and a research nurse engaged to assist the coroner in such matters.
10. Unintentional retention of surgical packs is a recognised risk of multiple surgeries. Loss of a pack may be contributed to by circumstances created by emergencies, the involvement of multiple surgical teams and incomplete communication between treating medical practitioners. Counting packs placed and removed, and recording the counts, is one means of controlling the risk. The risk may also be decreased by plain abdominal x-rays prior to leaving theatre in emergency abdominal surgical situations.
11. Although the LGH nursing records of retained packs were correct, the medical record was incomplete. Mr McKinley was transferred to the RHH with a relatively brief accompanying letter. I have no doubt that there was considerable discussion through numerous phone calls but examination of the medical records reveals no clear formal communication of the number of packs left in situ on the handover. It is not clear whether the nurses’ notes were copied and transferred and reference to only the surgical notes gave an incomplete record. How the possibility of the retained pack was realised and communicated to the RHH staff is not clear either but it appears that it was not until 13 June 2012. The pack retained in Mr McKinlay’s abdomen between 2 June 2012 and its removal on 14 June 2012 can be seen on the x-rays and CT scans.
12. However it is easy to appreciate how the retained pack might have been missed both on the handover and the X-ray in this case. He was extremely ill and being treated in circumstances of emergency. Most importantly I am satisfied that it did not contribute to Mr McKinlay’s death. The first major bleed and the multiple following bleeds suffered by Mr McKinlay after this surgery set the stage for poor healing and susceptibility to infection. He subsequently underwent, over a relatively short period of time, a large number of surgical procedures increasing the probability of contraction of infections. His generally debilitated state led to impaired immunity. The pack was sterile when inserted and did not erode into or impinge on the substance of his liver where the necrosis was first noticed. Retained packs may lead to infection at the surgical site but there is no evidence that retention of the pack in this case led to Mr McKinlay’s contracting the fungal infection. The evidence is to the contrary. A tissue biopsy taken at the Launceston General Hospital on 2 June 2012 showed the presence of a fungus of the same type on that date, suggesting that the source of the infection was introduced in the course of his multiple surgical procedures while still in Launceston. As Professor Turner explained, “although all procedures were performed under sterile conditions and the wounds suitably dressed, the longer the abdominal wall remains unclosed the higher the probability of colonisation by ambient organisms such as fungi”.
Comments and Recommendations:
13. I have decided not to hold in inquest into Mr McKinlay’s death. The investigation has sufficiently disclosed the identity of the deceased person, the time, place, the relevant circumstances concerning his death and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act. I am satisfied that no other person contributed to Mr McKinlay’s death. I do not consider that an inquest is likely to elicit any further information concerning the issues that I am required to determine.
14. Mr McKinlay died of complications relating to attempted curative surgery for his cancer. The surgery he undertook is difficult and complications are common and his death occurred despite the exercise of considerable care and skill and effort on the part of his surgeons and the staff of both hospitals.
15. Nevertheless I would recommend that both the Launceston General Hospital and the Royal Hobart Hospital review their respective procedures in regard to retained packs, if such a review is not already underway. To the extent that counting packs is to be used as a means of controlling risk then particular care should be taken to ensure accuracy of recording, consistency of recording between nursing and medical staff and clear and easily accessible communication of information between practitioners and hospitals, particularly on transfer between hospitals. Each hospital should also consider whether a practice of abdominal x-ray following emergency abdominal surgery to identify and reduce the risk of retained packs might be appropriate.
I convey my sincere condolences to Mr McKinlay’s family.
DATED: 23 May 2013 at Launceston in the State of Tasmania.