Record of Investigation Into Death (Without Inquest)
Corners Act 1995
Coroners Rules 2006
Rule 11
I, Rod Chandler Coroner, having investigated the death of
Beverley Dawn Scott
WITHOUT HOLDING AN INQUEST
Find That:
(1) Beverley Dawn SCOTT (“Ms Scott”) died on 3 March 2012 at 22 Walker Street in Rosetta.
(2) Ms Scott was born on 9 July 1944 and was aged 67 years. She was unmarried and retired.
(3) I find that Ms Scott died of hypoxic respiratory failure due to a traumatic chest injury from a fall at home.
Background:
Ms Scott lived alone in her home at Rosetta. Her past medical history included Addison’s Disease diagnosed in 1971 and which was managed with medication. In 1979 she suffered from Primary Ovarian Failure. Also in 1997 Ms Scott had a right femoral-popliteal bypass graft for an arterial thrombosis and since then had been taking the anti-coagulant Warfarin. Ms Scott had a close relationship with her aunt, Mrs Eva Barwick. Mrs Barwick describes her niece in these terms; “Beverley was a very kind but tough lady. She was very independent and would never ask for help from anyone. If there was something wrong, she would never let on because she would not want to worry anyone.”
In the morning of 29 February 2012 Ms Scott felt dizzy and unwell and she intended returning to bed. However, it appears that she collapsed and fell through a glass door. She sustained a period of loss of consciousness and when she awoke found herself lying on the ground surrounded by broken glass and blood. After some time she called for a taxi and was conveyed to her general practitioner. She had sustained deep lacerations to her left upper arm and left leg. These were dressed at the general practitioner’s surgery. Ambulance Tasmania was then called and Ms Scott was transported to the Emergency Department of the Hobart Private Hospital (“the Private”). She was there attended by Dr Pauline Rowan. Her wounds were assessed and arrangements were made for her to be transferred to theatre for debridement and suturing.
Ms Scott remained in the Emergency Department until being transferred to the operating theatre at about 8.00 pm. The surgery was to be undertaken by Mr Shrini Yallapu. There is no record of him carrying out a pre-surgical review. The surgery was uneventful and Ms Scott was returned to the ward in the early hours of 1 March. At this time her vital signs were stable.
On 1 March Ms Scott was reviewed by Consultant Physician Natalie Martin. She gave consideration to the cause of Ms Scott’s fall and obtained a history including information upon her Addison’s Disease, her use of Warfarin and her general state of wellness. Dr Martin recorded listening to the chest and finding no abnormal clinical signs.
On 2 March Ms Scott was seen by a physiotherapist who assessed her as safe for discharge from a mobility perspective. On the same day Ms Scott was seen by Mr Yallapu. He was satisfied with her progress and was happy for her to be discharged when given the go-ahead by Dr Martin. Also on 2 March Dr Martin reviewed Ms Scott. On this occasion she noted extensive bruising around Ms Scott’s back with no focal rib or spine tenderness. She authorised her discharge. At about 4.00 pm that day Ms Barwick and her husband collected Ms Scott from the Private and drove her home. At about 8.00 pm that evening Ms Barwick telephoned her niece who reported to her that she “was good” and that she was watching the football on TV.
Circumstances Immediately Prior to Death:
Mrs Wendy Smith is a neighbour of Ms Scott’s. She is also a registered nurse. At about 9.30 am on 3 March she answered her door. Ms Scott was there. She told Mrs Smith that she didn’t feel well. She complained of being hot and Mrs Smith noted that she “felt clammy.” She also noted that her breathing was shallow. Ms Scott was given a coffee. Her bandages, which had slipped down, were re-done. Ms Scott drank part of her coffee and then said that she would like to return home. Mrs Smith and her husband helped her. On the way Ms Scott “became faint and lost colour in her face.” When the trio reached Ms Scott’s back door Ms Scott had to sit on the step for a time to catch her breath. Mrs Smith called Ambulance Tasmania. Ms Scott was then assisted to her bed and Mrs Smith organised some clothes for her to take to hospital. She waited with her until the ambulance arrived.
The paramedics from Ambulance Tasmania report that Ms Scott advised that she had woken up that morning feeling very weak and faint-headed. She denied any pain in her chest or head and had not experienced palpitations, nausea, vomiting or diarrhoea. Her clinical observations were taken with her heart rate at 120 bpm, blood pressure of 116/91 and respiratory rate of 16 breaths pm. Her skin was cool and the oxygen saturation monitor was “not reading.” The paramedics then began to assess Ms Scott’s power in her legs. However, at this time she lost consciousness and suffered a cardiopulmonary arrest. Resuscitation efforts by the paramedics were unsuccessful and Ms Scott was declared deceased.
Post Mortem Examination:
State Forensic Pathologist, Dr Christopher Lawrence, undertook a post mortem examination. His report includes these comments:
“Autopsy reveals fracturing of the ribs and hemorrhage into the left pleural cavity. There does not appear to be significant ischaemic heart disease. There is a history of peripheral vascular disease. She is also has a history of adrenal insufficiency (Addison's Disease).
“Death appears to be due to the chest injuries which include 250m1s of blood in the left pleural cavity, multiple rib fractures, contusion of the lung and superficial laceration of the lung. There is also a perforation of the diaphragm. Some of the fractures could have occurred during resuscitation but histology of the rib fractures and the lung contusion show early organisation indicating that the injuries occurred days before death.
“The chronic adrenal insufficiency means that her body would not cope with the stress of the injuries like a normal person. In a normal person these injuries are unlikely to have caused death.
“Given the bruising present a chest X ray would probably have demonstrated the rib fractures, lung contusion and fluid in the pleural cavity. I am surprise that Mrs. Scott did not complain of chest pain or tenderness on examination.
“Toxicology reveals a greater than therapeutic level of dextromethorphan, a cough suppressing medication, found in cough and cold medications. It can cause drowsiness.”
Investigation:
Clinical Professor Anthony Bell has undertaken a review of the circumstances leading to Ms Scott’s death and her medical management at this time. That review has led to him making these observations:
- That Dr Rowan has advised that it is her practice when managing trauma patients to perform a full secondary survey but only record positive findings. Of this practice Clinical Professor Bell states; “I believe that the notes should state that a secondary trauma survey has been done. This then indicates to the continuing treating doctor that the tertiary survey must be done.” Clinical Professor Bell also makes the observation that, in his view, the past medical history should have forewarned Dr Rowan that Ms Scott needed to be considered in the geriatric age range and hence have regard to patient issues pertinent to that group.
- Of Dr Martin’s involvement he states that “a chest x-ray (should have been) ordered especially when the patient was found to have the extensive bruising before discharge.”
- That Mr Yallapu, as the treating surgeon, should have undertaken a tertiary trauma survey of Ms Scott and there is no documentary evidence of this having been done. If it had been done the bruising would have been noted which should have signalled the possibility of further traumatic injury.
The circumstances of Ms Scott’s death do, in the opinion of Clinical Professor Bell, demonstrate the need for:
-
Emergency Departments to have particular regard to the “special area of geriatric trauma” and
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All hospitals to have in place standard protocols for the assessment of trauma injuries including the tertiary trauma survey. Those protocols need to designate the consultant responsible for the secondary and tertiary surveys.
In Clinical Professor Bell’s opinion Ms Scott died of hypoxic respiratory failure due to a traumatic chest injury from a fall at home. He considered Ms Scott’s Addison disease and her Primary Ovarian failure to be significant noting that “both (contributed) to loss of bone density, muscular and connective tissue. This leads to a premature aging affect in these tissue and greater likelihood of injury with a fall.” Clinical Professor Bell makes this further comment relevant to the cause of death; “Furthermore Ms Scott was taking analgesic medication, though while necessary, have an effect on breathing, suppressing breathing and increasing the risk in this situation.”
Dr Lawrence agrees with the cause of death as articulated by Clinical Professor Bell.
Findings, Comments and Recommendations:
I am satisfied that Ms Scott died from hypoxic respiratory failure due to a traumatic chest injury from a fall at home.
Ms Scott’s fall caused her significant chest injuries, most notably multiple rib fractures. It is indeed surprising, as Dr Lawrence has noted, that they did not cause Ms Scott to complain of chest pain or tenderness. It may well be that she was a particularly stoic and uncomplaining individual which would be consistent with Mrs Barwick’s characterisation of her.
The regrettable feature of this case is the failure on the part of the three medical practitioners involved in Ms Scott’s care, even in the absence of her complaint, to detect the underlying chest injuries. Had they been detected the likelihood is that lifesaving treatment would have been initiated. This leads me to accept and endorse those comments made by Clinical Professor Bell, firstly with respect to the need for Emergency Departments to specifically recognise the special area of geriatric trauma and secondly, for hospitals to have in place standard protocols for the assessment of trauma injuries including a tertiary trauma survey.
I conclude by extending my condolences to Ms Scott’s family.
Dated: The 30 November 2012 at Hobart in the state of Tasmania.