MAGISTRATES COURT of TASMANIA CORONIAL DIVISION

   

In The Matter Of The
Coroners Act 1995

And

In The Matter Of An Inquest
Touching the Death of
Stanley Valentine WHILEY

Inquest held in Launceston from 12 to 14 March 2013.

Presamble:

1. Stanley Valentine Whiley died on 6 March 2010.  At the time of his death he was a resident of Tamar Park, a residential aged-care facility located at Legana near Launceston.  An inquest into Mr Whiley’s death was held from 12 to 14 March 2013.  These are my findings, comments and recommendations arising from that inquest.

Background:

2. Mr Whiley was born at Deloraine on 4 June 1942 and was aged 67 years.  He was married to Christine Whiley and was the father of two daughters, Kathryn and Susan.  Prior to his retirement he had worked as an employed and self-employed truck driver.


3. Mr Whiley became a resident of Tamar Park on 18 June 2009. 


4. Tamar Park is one of 35 aged care facilities owned and operated by Aged Care Services Australia Group (‘the Group’).  It comprises 3 wings known as South, West and North.  In all it has a 40 bed capacity.  In March 2010 it accommodated 36 residents.  Of these, one was classified as Low Care.  Of the remainder, 18 (including Mr Whiley) had been assessed as having High Care needs.  9 were assessed to have Medium Clinical Care needs and 8 had low or nil Clinical Care needs.


5. In March 2010 Ms Sandra Renshaw was the Facility Manager of Tamar Park.  She had held this position since 19 October 2009.  Ms Renshaw was a registered nurse being originally accredited in 1973.  She had general nursing experience along with more specialised experience in drug & alcohol services, aged care and palliative care.  She had not previously been employed as a Manager prior to her appointment to Tamar Park.


6. Ms Julie Reed is the Group’s Executive Director of Aged Care Services and is based in Melbourne.  She was the person to whom Ms Renshaw directly reported. 


7. Ms Julie Lord completed a Bachelor of Nursing from the University of Tasmania in November 2009.  On 23 February 2010 she was registered as a nurse in the State of Tasmania pursuant to the provisions of the Nursing Act 1995.  Ms Lord had commenced working at Tamar Park on 14 December 2009 and was initially employed as an extended care assistant.  In that capacity she had worked a total of 108.5 hours over seventeen days prior to 6 March 2010.  Ms Lord was the registered nurse on duty for the afternoon shift on 6 March 2010.  This was the second occasion that Ms Lord had worked as a registered nurse, the first having been for a night shift on either 23 or 26 February 2010. 
 

Events Preceeding 6 March 2010:

8. Dr Lee Jones is a General Medical Practitioner.  It has been his long-standing practice to attend Tamar Park on a weekly basis to treat its residents on an as-required basis.  Dr Jones carried out an assessment of Mr Whiley on 18 June 2009 being the day he was transferred to Tamar Park from the Launceston General Hospital (‘the LGH’).  At this time it was noted that Mr Whiley’s medical history included rheumatoid arthritis, decreased mobility, cognitive impairment and depression.  The reason for Mr Whiley’s transfer to Tamar Park was stated to be; “Unable to do self-management and care.  Needs assistance in daily activity.”


9. Mr Whiley’s medical condition, although declining, remained relatively stable until February 2010.  However, on 16 February Mr Whiley experienced seizures.  An ambulance was called and he was conveyed to the LGH where he was admitted.  Mr Whiley was diagnosed to have suffered a cerebral infarct or stroke.  He remained an in-patient at the LGH till 26 February when he was returned to Tamar Park.  In the days following Mr Whiley’s condition continued to deteriorate.  Tamar Park’s progress notes indicate that he was suffering from a chest infection, vomiting, nausea, confusion, incontinence and possibly oral thrush.  The notes also suggest that he was resistive to staff providing him with food, liquids, medication and medical care.  They specifically record that he refused medications on 2, 3 and 4 March. 


10. Dr Jones visited Tamar Park on 1 March 2010 and recorded that at this visit Mr Whiley was “in a poor state” and that his condition “appears terminal.”  He considered that Mr Whiley should be provided with palliative care.  The medications prescribed at this time included Norspan, a pain killing patch designed to combat Mr Whiley’s chronic pain caused by his rheumatoid arthritis.  In addition Dr Jones prescribed morphine sulphate to be used on an as-needs basis when the Norspan patch did not provide sufficient pain relief.  The dosage was 2.5 to 5mg to be given 4 hourly as required.  Dr Jones described the dose as ‘……a smallish dose, largely because he was a frail man and a higher dose may have been toxic rather than therapeutic.”


11. Dr Jones next saw Mr Whiley on 5 March.  He noted that he “continues to slowly fade.”  It was Dr Jones’ evidence that he did not expect to see Mr Whiley alive again. He was next due to visit the facility on 12 March. 

Circumstances Leading to Mr Whiley's Death:

12. On 5 March 2010 Ms Lord was contacted by Tamar Park’s receptionist.  She was asked whether she was available to work the next day on the afternoon shift.  She would be the registered nurse-in-charge.  Ms Lord informed the receptionist that she was nervous about doing the shift alone but was reassured that Ms Renshaw would be available by phone to provide assistance if needed.


13. Mr David Perry was the registered nurse-in-charge at Tamar Park for the morning shift on 6 March 2010.  He monitored Mr Whiley’s condition during the course of that shift.  At about 12.45 pm he appeared to be distressed and in pain.  Mr Perry administered a 5mg dose of morphine sulphate by subcutaneous injection.  He later recorded that Mr Whiley then settled quickly and appeared no longer to be in distress or pain. 


14. Mr Perry’s shift ended at about 3.30 pm.  Prior to this he undertook a handover with Ms Lord.  It included advice to Ms Lord that Mr Whiley was being managed as a palliative patient and that he was receiving subcutaneous morphine for pain relief each four hours.  Ms Lord was advised that the next dose was due at about 4.00 pm.  Mr Perry also informed her that another resident, Mrs Barbara Harper, was suffering with a rash but that he had not done anything to treat it. 


15. Extended care assistants Gaylene Buller and Sallyann Bramich were also rostered to work the afternoon shift of 6 March.  They commenced at 3.00 pm.  At 4.40 pm a third extended care assistant namely, Ms Leah Turmine also commenced work.

 
16. Ms Lord began her shift by attending to Mrs Harper.  She examined her and found that the rash covered about 60% of her body.  Mrs Harper also suffered from dementia and was unable to properly communicate with Ms Lord.  However, the rash was clearly irritating her as she was “constantly scratching at it.”  Ms Lord felt she needed some assistance in treating the rash.  She telephoned Dr Jones’ surgery.  No one answered as it was closed.  There was also no answer to its after-hours number.  She then telephoned GP Assist and spoke to a nurse.  She was advised that a doctor would call her back within 15 minutes. 

17. Ms Lord then commenced the pre-dinner medication rounds.  All of the 36 residents required medication.  This was the first time Ms Lord had carried out an afternoon medication round at Tamar Park.  During the round Ms Lord attempted to give Mr Whiley his oral dose of Prednisolone but he would not open his mouth to take the tablet.  She described him at this time as being “semi-conscious” and “quite defiant.” 

18. By about 4.30 pm she had completed the medication round for North and West wings but South wing remained.  By this time Ms Lord had not had a return call from GP Assist.  She decided to telephone Ms Renshaw. 


19. Ms Lord asked Ms Renshaw whether Tamar Park held any oral Phenergan in stock and whether she could administer it to Mrs Harper without a doctor’s authorisation.  She was advised by Ms Renshaw that none of this medication was in stock and in any event it required a doctor’s authority to administer.  Ms Lord then contacted a local pharmacy by phone.  She spoke to a pharmacist who suggested that Mrs Harper be given an oral Phenergan tablet taken from another patient’s Webster pack.  Ms Lord was not certain about this advice and telephoned Ms Renshaw again.  She was told that this could not be done without a doctor’s authority.  At this time it was about 4.50 pm.  Nurse Lord then received a return call from a doctor at GP Assist.  The doctor expressed his concern that Mrs Harper may become anaphylactic.  Nurse Lord was directed by the doctor to write out a drug order for Phenergan to be administered by intra-muscular injection.  She was instructed to fax the written order to GP Assist for the doctor to sign and he would then forward it direct to the pharmacy.  Ms Lord wrote out the drug order but then had difficulty operating Tamar Park’s fax machine.  It was not until about 5.45 pm that she was able to send off the drug order.  In the meantime she had telephoned the pharmacy to advise of the arrangement and to ensure that they had Phenergan in stock.  Ms Lord was aware that the pharmacy closed that day at 6.00 pm and it was becoming touch-and-go whether the medication could be accessed in time. 


20. In the period that Ms Lord was attempting to secure some Phenergan for Mrs Harper she also was undertaking the medication round in South wing.  From about 4.00 pm onwards she was approached on several occasions by the extended care assistants who reminded her that Mr Whiley’s next dose of morphine sulphate was overdue.  It needed to be administered so that they could then carry out his personal care needs.  Shortly before 5.00 pm Ms Lord was again reminded of the need to attend Mr Whiley.  She then went to the drug storage room with Ms Buller.  In her affidavit Ms Lord describes events surrounding the drawing of the morphine sulphate and its administration in these terms;


“I went to the drug storage room at the facility and removed a packaging of morphine for MR WHILEY.  I quickly looked at the packaging and incorrectly saw 1mg / 1ml whereas the correct ampule strength was 10mg/1ml.  The medication order was for 2.5 – 5mg morphine sub/cut per four hours.  I drew up 25mg/2.5ml as the correct packaging was for 10mg/1ml.  I had never administered morphine before and as previously mentioned had not viewed the packaging and labelling of morphine ampoules.  I was not familiar with the standard dosage of morphine.


“I asked one of the carers, Gaylene Buller, who was with me at the time to check the dosage with me.  Buller double checked the dosage but did not notice my mistake either.  Buller was with me when I administered the dose to Mr Whiley in the sub cutaneous tissue of his abdomen to the right of his belly button at 5.00 pm.  The drug was signed by me and initialled JL.”


21. It is common ground that the 25mg of morphine sulphate administered to Mr Whiley was five times greater than the maximum dosage prescribed by Dr Jones and ten times greater than the dosage Ms Lord intended to administer.


22. It was at about 6.00 pm that the pharmacy delivered Mrs Harper’s Phenergan to Tamar Park.  Ms Lord then administered a dose by intro-muscular injection with an almost immediate beneficial effect.


23. Ms Lord had not checked on Mr Whiley following the administration of his morphine sulphate because she was occupied attending to the medication round on South wing.  The round would normally have been completed about one hour earlier.  However, at about 5.30 pm Mr Whiley was attended by extended care assistants.  He was turned to prevent the development of pressure sores.  The assistants reported to Ms Lord that Mr Whiley was alive but resistive to care.


24. It seems that Mr Whiley was not attended again by any of the Tamar Park staff during the next 4½ hours.  At about 10.00 pm Ms Lord returned to the drug storage room intending to draw Mr Whiley’s next dose of morphine sulphate.  She was accompanied by Ms Turmine.  Ms Lord calculated and then drew the dose.  In doing so she realised that she had made an error in her calculation of the earlier dose.  She did not inform Ms Turmine of her error at that time.  Together they then went to Mr Whiley’s room intending to administer the morphine sulphate.  They then discovered that Mr Whiley had died. 


25. Ms Lord was distressed to find Mr Whiley deceased.  She told Ms Bramich of the dosage error.  Ms Bramich then attended at Mr Whiley’s room and was able to see that he was deceased.  She then telephoned Ms Renshaw to advise of the situation.  Ms Renshaw then promptly attended at Tamar Park.


26. The exact time of Mr Whiley’s death cannot be determined.  The evidence only permits a finding that he died in the period after about 5.30pm when checked by extended care assistants and before about 10.00pm when Ms Lord and Ms Turmine attended his room. 

Cause of Death:

27. S28(1)(c) obligates me, if possible, to make a finding upon the cause of death.  The evidence shows, as I have recited, that Mr Whiley, only hours before he was found deceased, had been administered a dose of morphine sulphate which was ten times greater than the maximum prescribed dose.  A focus of the inquest was whether this overdose was a factor which caused or contributed to Mr Whiley’s death.   


The Expert Evidence


28. State Forensic Pathologist, Dr Christopher Lawrence carried out a post-mortem examination of Mr Whiley.  Dr Lawrence’s report includes these comments:


“Autopsy reveals evidence of an old stroke and a recent stroke.  There is severe ischaemic heart disease with early changes of infarction.  There is aspiration pneumonia which may be due to the stroke or possibly the morphine.  Toxicology reveals a blood morphine level of 0.2mg/L which is at the lower end of the lethal range.  It is difficult to know what Mr Whiley’s tolerance to morphine was, and a tolerant person may survive this morphine level.  He was found dead at 22.00h and was given the 25mg of morphine at 17.00h, but it is not clear when death occurred.  I did expect the morphine level to be a bit higher but it is possible that some of the morphine could have been metabolised during a period of respiratory depression leading to aspiration pneumonia.


“Either the ischaemic heart disease or the stroke causing aspiration pneumonia could have caused death at any time as he was obviously in a pre-terminal state.”


29. In his report Dr Lawrence stated that in his opinion the cause of Mr Whiley’s death was the “combined effects of ischaemic heart disease, left cerebral infarct and morphine intoxication.” 


30. Dr Lawrence also gave evidence at the inquest.  It included these opinions:


• That prior to 5.00pm on 6 March Mr Whiley was probably suffering from aspiration pneumonia and that imminent death was inevitable.  If this was so it was reasonable to accept that the aspiration pneumonia was the result of ischaemic heart disease and/or left cerebral infarction. 

• That it was possible that the morphine did not contribute to the death and that the ischaemic heart disease and/or the cerebral infarction were the more likely causative factors.

• That the closer death occurred to the administration of the morphine the more it was likely to have been causal. 

• That the administration of the morphine may have been ‘the straw that broke the camel’s back.’


31. Mrs Miriam Connor is a forensic scientist and the toxicology manager for Forensic Science Service Tasmania.  She carried out an analysis of a sample of Mr Whiley’s post-mortem blood.  She confirmed that it indicated the presence of morphine at a concentration of 0.2 mg/L.  This level, she said, was within the fatal range but at the lower end.  Mrs Connor identified several factors which made Mr Whiley more vulnerable to the toxic effects of the morphine.  These were:


• His low weight.  He weighed just 50kg.

• His poor state of health.

• His state of semi-consciousness.

• The presence of the depressant diazepam in the blood (recorded at less than 0.05 mg/L) which had the potential to exaggerate the depressant effects of the morphine.


However, Mrs Connor was unable to say whether the morphine caused or contributed to the death.  She simply acknowledged that it may have done. 


32. Dr Ross Ulman is a widely experienced consultant physician and rehabilitation physician who provided expert testimony upon a range of medical and nursing issues.  One of those was the causal relationship, if any, between Mr Whiley’s death and the morphine overdose.  On that subject Dr Ulman expressed these views:


a) That he did not accept, on his interpretation of Dr Lawrence’s post-mortem report, that the morphine overdose was a certain cause of Mr Whiley’s death.

b) That the combined effect of the ischaemic heart disease and the left cerebral infarct was a causative factor.  Individually, each was more certain to be causative than the morphine overdose. 

c) Of Dr Lawrence’s opinion that the morphine overdose may have been ‘the straw that broke the camel’s back’, Dr Ulman said; “Well again I would put it in terms of probability or possibility rather than certainty but it’s not out of the question.”

d) As to the possible fatal effects of the morphine he made these comments:


"……so what we are interested in is whether that morphine changed the trajectory of what was already happening because he was in a state of gradual deterioration over several days and my interpretation of it is that on one extreme it didn’t change the trajectory at all – in other words he died – would have died when he died even if this overdose hadn’t been given and on the other extreme is that it did change the trajectory and brought forward death by a few hours…..”;


“……on the balance of probabilities the morphine, if it had an effect at all, it had an effect by a maximum of a few hours and at the other end of the spectrum it didn’t have any effect at all – it didn’t change the trajectory – Mr Whiley would have died when he died even if this overdose hadn’t occurred.  I can’t rule that out.” 

And,

“All I can say is this is what’s happened and it’s either somewhere between zero on the one hand…….of the spectrum and a few hours at the other end and I don’t know where it is on that spectrum because there’s no way of me – there’s no evidence that I can think of to help me decide that.” 


Evaluation


33. As counsel assisting has submitted, the question for me to determine on the subject of causation is whether Mr Whiley’s life would have been extended to a material degree had the morphine overdose not been administered.  My determination of this question requires me to be satisfied on the balance of probabilities.  It is not sufficient for me to be satisfied that the morphine overdose was a possible cause of death.  Rather, I must be persuaded that it was a probable cause. 


34. Mr Whiley was overdosed at about 5.00pm.  The dose was five times greater than the prescribed maximum.  Five hours later he was found deceased.  At first blush these bald facts would suggest a causal link between the overdose and death.  However, the true situation is more complex.  Mr Whiley was terminally ill and was receiving palliative care only.  In the opinion of Dr Lawrence Mr Whiley was already suffering from aspiration pneumonia when he was administered the morphine by Ms Lord.  At this time his life expectancy was measurable in hours rather than days. 


35. It was the clear tenor of the evidence of both Drs Lawrence and Ulman that Mr Whiley’s ischaemic heart disease and left cerebral infarct were factors causative of death and both were more certain to have been causal than the morphine overdose.  His post-mortem report suggests that Dr Lawrence was of the view that the morphine overdose was also a causal factor.  However, his testimony given at the inquest was more equivocal.  In the result the views of Drs Lawrence and Ulman were similar, that is that it was possible that the morphine overdose brought forward Mr Whiley’s death by a short time, perhaps just hours, but that it was similarly possible that death would have occurred at the time it did, even if the morphine had not been given. 


36. A factor which would have assisted in establishing whether there was a probable causal link between the overdose and Mr Whiley’s death was a finding upon the precise time of death.  If the evidence had shown that Mr Whiley died within a short time of receiving the morphine then the inference that the overdose was causally linked to the death would be easier to make.  Conversely, if it was established that death occurred near to 10.00pm then a causal link between it and the morphine overdose would be far less likely.  Unfortunately the evidence upon the time of death is imprecise and unhelpful, it only permitting me to find that Mr Whiley died at an unknown time in the 4.5 hour period between 5.30pm when last observed by Tamar Park staff and about 10.00pm when he was found deceased. 


37. My consideration of all the relevant evidence leads me to conclude that I cannot be satisfied, to the requisite degree, that the morphine administered by Ms Lord on 6 March was a factor which caused or contributed to Mr Whiley’s death.  In the result I find the cause of Mr Whiley’s death to be the combined effects of ischaemic heart disease and left cerebral infarct.

Contribution:

38.  S28(1)(f) of the Coroners Act 1995 requires me, if possible, to identify any person who contributed to Mr Whiley’s death.  I have determined that the morphine overdose delivered by Ms Lord did not cause or contribute to Mr Whiley’s death.  Rather death was attributable to the effects of underlying natural disease.  These findings make it unnecessary for me to consider whether any person contributed to the death.

Formal Findings:

39. I make these findings in accord with s28(1) of the Coroners Act 1995:


(i) The identity of the deceased is Stanley Valentine Whiley,

(ii) The death occurred on 6 March 2010 at Tamar Park, a residential aged-care facility located at Legana near Launceston,

(iii) The cause of Mr Whiley’s death was the combined effects of ischaemic heart disease and left cerebral infarct. 

(iv) No person contributed to the cause of death.
 

Comments and Recommendations:

Comment Related to Ms Lord


40. Ms Lord was a particularly inexperienced nurse.  She had been registered less than a fortnight prior to 6 March 2010.  Prior to that date she had worked just one shift as a nurse at Tamar Park and that was a less demanding night shift.  Further, she had not received two days’ orientation/buddying as a nurse contrary to Tamar Park protocols.  On 6 March she was responsible for the nursing care of 36 residents, half of whom were classified as High Needs.  All  required medication, one, namely Mr Whiley was being palliated and another, Mrs Harper, was in need of immediate nursing attention.  Of this situation Dr Ulman commented; “Of course it was (Ms Lord) who made the mistake; but she was put into circumstances which markedly increased the likelihood of such a mistake.  In other words she is the victim of a system breakdown not of her making.”  In a similar vein, Dr Margaret Winbolt, who provided expert nursing evidence to the inquest said this; “I believe however Ms Lord was in a situation where a new graduate without the necessary experience to deal with a complex environment, the associated high level of responsibility and to prioritise a huge case load and competing demands could not be expected to function well.”


41. I endorse the comments made by both Dr Ulman and Dr Winbolt.  Ms Renshaw made a serious misjudgement in appointing Ms Lord as the sole nurse on duty for the afternoon shift of 6 March.  It was a decision which unfairly exposed Ms Lord and the residents to very real risk.  It is apparent that the events of 6 March have had a significant impact upon Ms Lord’s emotional well-being and her nursing career.  That impact, I suspect will not be totally ameliorated by my finding that the morphine overdose administered by her was not causally related to Mr Whiley’s death.  Any support which the Group may be able to provide Ms Lord to assist her recovery from this tragedy would, I am sure, be welcome. 


Recommendations


42. I am advised that following a review of the circumstances of Mr Whiley’s death the Group has taken these steps:


(a) Conducted one-on-one education with its extended care workers at Tamar Park on checking medications as a witness if a second registered nurse or enrolled nurse is unavailable to perform this role.

(b) Amended the staff induction (orientation) programme policy at Tamar Park to ensure that the process and periods for differing staff are more clearly defined.  Relevant to this case the policy provides for a registered nurse with less than one year acute or aged care experience to receive five days of orientation as a ‘buddie’ shift. 

Both Dr Ulman and Dr Winbolt considered both these steps to be appropriate. 

 
43. It is my understanding that Standards and Accreditation Agency Ltd (‘the Agency’) is the body responsible for the formulation of standards of best practice in the aged-care sector.  Counsel assisting has proposed that I recommend for the Agency to review the circumstances of this matter with a view to:


a. Assessing the adequacy of the form and content of the orientation and induction process for registered nurses who commence employment at an aged care facility in Tasmania. 

b. Considering the qualifications and experience that a registered nurse should have as a minimum before being placed in charge of an aged-care facility and whether they should be mandated. 

c. A review and assessment of the training and level of competence required of ‘responsible persons’ (including extended care assistants) for the purpose of checking the preparation and administration of all narcotic substances, and a scheme for the validation of that competency at regular intervals.

d. A review of the medication administration competency tool and assessment process and its suitability as a competency tool. 


44. I agree with the proposed recommendations and adopt them. 
 
I wish to acknowledge the work done by Mr C N Dockray as counsel assisting.  It has been of the highest standard and of considerable assistance to me.  Too, I appreciate the assistance given by counsel for Ms Lord and for Tamar Park. 
 

I conclude this inquest by extending my sincere condolences to Mr Whiley's family.

Dated in Launceston on 18 day of July 2013.

 

Rod Chandler
Coroner