MAGISTRATES COURT of TASMANIA
In The Matter Of The
Coroners Act 1995
In The Matter Of An Inquest
Touching the Death of
Joanne Jean YORK
FINDINGS, RECOMMENDATIONS AND COMMENTS of Coroner Rod Chandler following an inquest held in Hobart.
1. Mrs Joanne Jean York died at 1.00 pm on 31 January 2010 in the Intensive Care Unit of the Royal Hobart Hospital ('the Royal'). Her death occurred 10 days after she had undergone gastric banding surgery carried out by Mr Stephen Wilkinson at the Hobart Private Hospital ('the Private'). Mrs York was aged 26 years being born on 24 May 1983. She resided at Geeveston. She was married to Robert Lawrence York. They had two children respectively aged 6 and 3 years.
Events Preceding the Gastric Banding Surgery
2. Since her teenage years Mrs York had had difficulty managing her weight. On 9 October 2008 she attended Dr Claire Dale at the Huon Valley Health Centre and sought assistance with her weight problem. Different options were considered including a diet and an exercise-based programme, weight counselling and medication. Gastric banding was discussed as a last resort. At this time Mrs York weighed 166kg. The Centre's records show that over the ensuing months Mrs York's weight did not decrease but in fact increased. On 27 January 2009 it was recorded at 172kg and three weeks later at 175kg. On 31 March 2009 Mrs York was seen by Dr Adriane Hebblewhite at the Centre. Her weight problem was discussed. She reported that both her mother and her sister had undergone successful lap banding procedures with her sister loosing 80kg. Dr Hebblewhite was persuaded to refer Mrs York to Mr Wilkinson for weight loss surgery. She explained her reasons in these terms; "(Mrs York) was desperate to lose weight. She had major mobility issues. She was very depressed. She said that she had tried everything to lose weight without success. She said that the previous counselled diet and exercise programme wasn't working. She said to me that "everyone in my family is so obese and the only thing that ever helped any of them is lap banding - the only way people in my family lose weight is by lap banding."
3. Mrs York first saw Mr Wilkinson on 6 December 2009. Although Dr Hebblewhite's referral had been made almost 9 months previously it had been necessary for Mrs York to wait for this period so that she qualified for private health cover in respect of the intended surgery. In the meantime, Mrs York had also been referred to surgeon, Mr Robert Linacre for the laparoscopic removal of her gall bladder and gall stones. That procedure was carried out on 22 December 2010. It was straight forward and the postoperative course was uneventful. However, there was some concern that not all the stones had been removed and arrangements were made for a gastroenterologist to carry out an endoscopic ultrasound to determine whether there were any stones left in the bottom of the common bile duct. This was done on 11 January 2010 and no stones were seen. Mr Linacre was aware of Mrs York's upcoming gastric banding surgery and he therefore sent to Mr Wilkinson copies of the investigation so that he was fully informed.
4. When Mr Wilkinson first attended Mrs York he recorded her weight at 175kgs. She was 173 cms tall and had a body mass index (BMI) of 58.5. He explained to her the lap banding procedure. She agreed to proceed and it was scheduled to take place on 21 January 2010.
5. The gastric banding procedure was carried out by Mr Wilkinson at the Private on 21 January 2010. He has reported on the surgery in these terms; "The operative procedure took approximately 45 minutes and was uneventful. There was a small hiatus hernia which is not uncommon in these patients and this was reduced and repaired. The band was placed in the usual position and fixed with the usual technique of sutures……Post-operatively the patient appeared to make an uneventful recovery." Mrs York was routinely discharged from the Private the day following her surgery. Beforehand she underwent a contrast swallow with gastrograffin to ensure that there was no leakage from the stomach. The study was negative.
6. No criticism is made of the technique used by Mr Wilkinson for the surgery nor is there any criticism of the manner in which it was carried out.
Events Preceding Mrs York's Death
Re-Presentation at the Private's Emergency Department
7. Five days after her surgery Mrs York re-presented at the Private's Emergency Department. ('the ED') She was taken by her husband who reported that "a day or two (after the gastric banding) Joanne had a high temperature of 39 degrees and she was saying she just didn't feel well." At 3:05 pm she was seen by Dr Sonya Peters. It was recorded that Mrs York presented with nausea, vomiting, diarrhoea and chest pain upon a history of lap band surgery five days previously. Dr Peters noted that Mrs York looked pale and miserable. She was sweaty and dry-reaching. Her heart sounds were dual and her chest was clear on auscultation. She had no leg swelling or calf tenderness. Dr Peters also recorded that she was unable to examine Mrs York's abdomen as she felt nauseous and started retching when she tried to lie on her back.
8. On clinical examination Mrs York was febrile (temperature of 39.3 degrees), tachycardic (pulse rate 117/min) and had a mildly increased respiration rate at 22/min. Her oxygen saturation's were 95% and her blood pressure was 161/89.
9. At this point Dr Peters entered in the records under the heading "IMP" (Impressions):
"Post op lap band
At risk of PE"
10. Dr Peters explained that her initial diagnosis for Mrs York was sepsis due to a post-operative complication of aspiration pneumonia or perforation. However, this was not expressly recorded in the hospital notes.
11. Dr Peters then initiated some investigations including an ECG and the taking of blood to facilitate a full blood count and testing of C-reactive protein, urea, electrolytes and creatinine and d-dimer. Dr Peters explained that the purpose of the full blood test was to determine the level of white blood cells. An elevated count was an indication of infection. Similarly, an elevated C-reactive protein (CRP) result was also an indication of infection or inflammation. Urea, electrolytes and creatinine levels are an indicator of electrolyte imbalance whilst the purpose of a d-dimer test is to indicate whether there is a probability of a pulmonary embolism. Dr Peters also ordered x-rays of the chest and abdomen.
12. The x-ray report included these findings; "There is minor right basal atelectasis but no convincing evidence of pneumonia. No pneumoperitoneum is detected. No definite abnormality of bowel gas pattern is discerned." Dr Peters then recorded "no pneumonia" and "no air under diaphragm" in the notes. These findings, in her opinion, excluded the likelihood that Mrs York had a major perforation of either the stomach or the bowel but it did not exclude the possibility of a micro-perforation.
13. The preliminary full blood test showed a white cell count of 17.8 blood cells per microL with a neutrophil count of 14.2. Both these are elevated results indicating an infection or inflammation but not its location within the body. Having received these results along with those for the x rays Dr Peters then telephoned Mr Wilkinson. In that conversation Mr Wilkinson made the decision for Mrs York to be admitted to a ward. He directed that intravenous fluids be continued. He also directed that intravenous antibiotics be commenced and nominated cefazolin and metronidazole. These, Dr Peters explained, are used to cover infections of both the respiratory and gastrointestinal tracts.
14. Later that afternoon Dr Peters received the CRP and d-dimer test results. The former was recorded as 448 which she agreed was a "good indication" that a bacterial infection was present. The d-dimer test was positive. Dr Peters did not inform Mr Wilkinson of these further results.
15. Dr Peters last saw Mrs York at 6.30pm on 26 January. On this occasion her presentation was slightly different in that she complained of pleuritic left sided chest pain and shortness of breath when standing. She considered that she was at moderate risk of a pulmonary embolism and ordered a CT pulmonary angiogram of the lungs to exclude this possibility. Dr Peters finished her shift that night at 7.00pm and was unaware that the CT scan had not proceeded because Mrs York was unable to lie flat. Dr Peters' replacement was Dr Edmond Albert. At 8.00 that night he made an entry in the notes which included this comment; "Infection still more likely, but cover with 100mg clexane od." The purpose of prescribing clexane was to treat possible thrombosis.
16. Sometime before 10.00pm on 26 January Mrs York was transferred to the Private's Medical Short Stay Ward and into the care of Mr Wilkinson.
Mr Wilkinson's Treatment and Care
17. The first issue to address is the timing and extent of Mr Wilkinson's involvement in Mrs York's care whilst she was in the ED. In a report written for the coroner Mr Wilkinson states;
"The 26 January was my all-day operating day at the Hobart Private Hospital. I initially discussed the patient with the treating doctor in the A&E and requested a number of investigations, and in between operating cases, I went down to A&E to see the patient. The patient was as described above. My clinical examination did not reveal any specific findings, mainly due to the patient's obese state, but in particular, there did not appear to be any signs of intra-abdominal sepsis - her abdomen had tenderness over the wounds but was not rigid or tense. Her air entry was poor. She was about 2% dehydrated, from poor fluid intake and several vomiting episodes. At that stage she had a chest x-ray with poor basal expansion consistent with atelectasis. Her abdominal x-ray did not show any abnormality. Her total WCC was raised (17.8). She had blood cultures taken, and I advised that the diagnosis was probably basal atelectasis and that she should be admitted, re-hydrated with IV fluids, and undergo CT scanning."
18. 26 January 2010 was Australia Day and a public holiday. As such the Private did not have any operations scheduled for that day. The ED records do not contain any reference to Mr Wilkinson attending Mrs York on that day. Particularly there is not any reference to a clinical examination made by him of Mrs York. It was Dr Peters' evidence that had Mr Wilkinson advised her in their 'phone conversation that he would attend Mrs York in the ED then she would have recorded this fact in the records. She did not do so.
19. I am satisfied that those assertions made by Mr Wilkinson in the paragraph which I have set out above are almost all incorrect and blatantly so. He was not on the 26th operating all day and he did not on that day attend Mrs York and carry out an examination of her. Particularly, he did not examine her abdomen as he claims and hence there is no basis for his assertion that it "was not rigid or tense." I do accept that Mr Wilkinson did have one 'phone conversation with Dr Peters but that was after she, and not Mr Wilkinson had initiated all investigations and after she had received the x-ray and preliminary blood test results. I accept that in that phone conversation Mr Wilkinson did direct that Mrs York be admitted and that intravenous fluids be maintained. However, I do not accept that Mr Wilkinson ordered a CT scan. It is, in my view, more likely that this was requested by Dr Peters following the receipt of the positive d-dimer test and her second examination of Mrs York at 6.30pm.
20. At the time of her admission Mr Wilkinson's working diagnosis for Mrs York was atelectasis (collapse of the lung). In cross-examination he expanded on his diagnosis in these terms; "…..what I'm trying to make clear is that I thought the patient had a chest septic problem, and that was manifest by atelectasis on the radiology and it was manifest in some clinical features." Mr Wilkinson further explained that in these circumstances the standard approach was to admit the patient and to observe them for the evolution of any further signs and symptoms.
21. The Private's short stay records show that Mr Wilkinson first saw Mrs York at 9.30am on 27 January and thereafter at 10.20am on 28 January and at 11.30am on 29 January. Mr Wilkinson did not make any entry in the records himself. However, nursing staff have noted his directions. On 27 January a leg ultrasound was ordered to exclude the possibility of a deep vein thrombosis. On 28 January a further chest x-ray (but not an abdominal x-ray) was ordered to "check progress." Intravenous antibiotics continued to be administered for the duration of Mrs York's stay.
22. From the time of her admission to the ward a clinical chart was maintained to record variations in Mrs York's temperature, pulse, respiration and blood pressure. The chart shows significant variations of temperature. Spikes of 38.9 and 38.5 were recorded respectively at 8.20pm on 27 January and at 8.00pm. on the following day. Low recordings of 35.9 were made at 3.00pm on 27 January and again at 4.00pm on 29 January. The last entry shows Mrs York had a temperature of 37.7 at 5.00am on 30 January.
23. The chart includes a graph of Mrs York's pulse rate. It reveals a clear upward trend peaking at 150bpm at 12.40am on 29 January and being maintained just below that rate for the balance of that day. The last recording was 140bpm made at 5.00am on the 30th.
24. When Mrs York was first admitted her oxygen saturation level was recorded at 99% but it gradually declined over time. At 4.00pm on 29 January it was recorded at 83%. An improvement to 90% was noted at 9.00pm that day but it had deteriorated to 88% when last checked at 5.00am the next day. Similarly, the records show a decline in Mrs York's blood pressure. The first entry made at 6.30am on 27 January shows a blood pressure of 131/83. This contrasts with the last entry of 119/65 made in the early morning of 30 January.
25. Despite the clinical chart clearly indicating an on-going infection and pathological deterioration in Mrs York's condition no steps were taken to vary her treatment or to further investigate the source or location of that infection prior to her discharge.
Circumstances of the Discharge
26. As I have already noted Mr Wilkinson saw Mrs York at 11.30am on 29 January. He told her that she may go home the following day if there was no change in her condition. In anticipation of that happening he provided a script for an antibiotic for her to take at home.
27. On the night of 29 January Mrs York was nursed by Ms Lisa Thornley, a registered nurse with 40 years' experience. She was aware that Mrs York was hoping to be discharged the following day. At 5.00am on 30 January she took Mrs York's observations recording her temperature at 37.6, a heart rate of 140bpm, a respiration rate of 20, a blood pressure of 119/65 and an oxygen saturation rate of 88% on room air. Nurse Thornley considered these observations to be at variance with her previous presentation and she therefore made this entry in the short-stay notes;
"Patient non-compliant with deep breathing; coughing and use of incentives barometer; mobilizing; sats down to 88 on room air; action: patient encouraged to move, sit high in bed up in bed, oxygen via nasal prongs of 3 litres, and continue monitoring."
28. Nurse Thornley's shift ended at 7.00am on 30 January. Nurse Leanne Cowen was the incoming nurse who took over Mrs York's care. The incoming nurse-in-charge was Nurse Sarina Lyne. In the formal handover Nurse Thornley informed both Nurse Cowen and Nurse Lyne of the latest observations made of Mrs York and of her concerns that she wasn't sufficiently well to be going home.
29. When Nurse Cowen first saw Mrs York that morning Mrs York informed her that Mr Wilkinson had told her the day before that she could go home. Nurse Cowen explained that her discharge would have to be discussed with Mr Wilkinson. It was also explained that her current course of intravenous antibiotics would have to be finished and that the antibiotic syrup which Mr Wilkinson had provided a script for the day before would not be available from the pharmacy until about 11.00am.
30. At about 9.00am Nurse Cowen gave Mrs York a hot towel wash. At this time Nurse Cowen did not observe any signs of distress, shortness of breath or clamminess. She suggested that Mrs York take a walk around the ward but she would not do so explaining that she did not want others to see her. Nurse Cowen did not take any observations of Mrs York's vital signs because she was "side-tracked" by the need to assist with another patient.
31. Sometime after 10.00am on 30 January Nurse Tillie Horak had a 'phone conversation with Mr Wilkinson concerning one of her patients. During this conversation Nurse Cowen requested Nurse Horak to inform Mr Wilkinson that Mrs York was keen to go home and ask if he gave permission for her to be discharged. It is not in dispute that Nurse Horak passed on this request to Mr Wilkinson. However, there are some differences on the evidence with respect to the balance of the conversation. This is a matter which I will deal with at this point.
32. In a report provided to the coroner Mr Wilkinson has said;
"On the 30th January, I was rung by the nursing staff at around 9 or 10am. I had planned a ward round later that day, but the patient's mother had arrived on the ward, and the patient was strongly requesting to go home then. She had remained afebrile, the IV line was now down, the patient was mobilizing and no longer complaining of pain, and she was re-hydrated and tolerating oral fluid intake. I therefore made the decision based on this information that the patient could go home without having to wait for me to come in and review her."
33. These assertions are contrary to Nurse Horak's testimony. She told the inquest that she had the conversation with Mr Wilkinson in Nurse Cowen's presence. Nurse Cowen had not provided her with any information relating to Mrs York's condition and no such information was sought by Mr Wilkinson. This exchange took place between counsel-assisting and Nurse Horak:
Counsel: "Did you give Mr Wilkinson any clinical information at all concerning the patient?
Counsel: "Did you say anything to him concerning whether she was febrile or afebrile?"
Counsel: "Did you say anything to him about her IV line?"
Counsel: "Did you say anything to him about whether or not Mrs York was mobilizing?"
Counsel: "Or whether she'd been complaining of pain?"
Counsel: "Or whether she'd been tolerating or not tolerating oral fluids?"
Counsel: "Or about the state of hydration?"
Counsel: "Your statement indicates that, in fact it says, I'm sorry, that Mr Wilkinson replied that if she really wanted to go she could. Do you recall saying - him saying anything further about her going home?"
34. Nurse Horak was not challenged on any of her above evidence. It was largely corroborated by Nurse Cowen. She said that during the 'phone conversation she had Mrs York's file on hand to answer and questions but no information was sought.
35. In his evidence Mr Wilkinson acknowledged the possibility that he did not receive any clinical information upon Mrs York in his conversation with Nurse Horak. More tellingly he accepted that if he had been informed of the observations obtained by Nurse Thornley at 5.00am that morning he would not have authorised her discharge.
36. I am satisfied that the version of Nurses Horak and Cowen concerning the phone call is correct. It follows that Mr Wilkinson permitted Mrs York to be discharged without having seen her seen since 11.30am the previous day and without having sought or received any information upon her state of health since that time.
Family Pressure for Mrs York to go Home?
37. It was Mr Wilkinson's evidence that in his telephone call with Nurse Horak it was conveyed to him "that there was a lot of pressure in the ward for her to go home." He said that it was because of this 'pressure' that he "acquiesced" to her discharge. Relevant to 'pressure' Nurse Cowen made this entry in the short stay notes the day after Mrs York's discharge; "P/c to Dr. re patient going home, patient keen to go. Family visiting from W.A…….Patient asked to stay until Dr comes in. Patient not wanting to stay as mother here and keen to get home." It was Nurse Horak's evidence that she simply relayed to Mr Wilkinson the information provided by Nurse Cowen, namely that Mrs York was "keen to go home" and nothing more. Nurse Lyne did not overhear the conversation between Mr Wilkinson and Nurse Horak but she says that she was afterwards informed that Mr Wilkinson had given permission for her to be discharged. She said that prior to Mrs York leaving she stressed to both her and her mother, Mrs Christine Caudwell, that it would be a good idea for them to wait to see Mr Wilkinson but this suggestion was rejected. She acknowledged that she did not know if or when Mr Wilkinson would be attending the ward that day, it being a Saturday.
38. It is unclear from Mrs Caudwell's evidence when she learned of her daughter's possible discharge on 30 January. The likelihood is that she was informed by Mrs York the day beforehand following Mr Wilkinson's last visit. It follows in my view that it is likely that Mrs Caudwell attended the Private in the morning of 30 January with the expectation that she would be taking her daughter home. Mrs Caudwell denied that either she or her daughter exerted any undue pressure on the nursing staff to facilitate Mrs York's discharge. She also denied receiving any nursing advice that Mrs York wait to see Mr Wilkinson before leaving the hospital.
39. As can be seen there are some conflicts upon the evidence surrounding Mrs York's discharge. However, I am able to make some observations. It is likely in my view that Mrs York was keen to leave the hospital in the morning of 30 January and that she conveyed this to Nurse Cowen. It is probable that she did not want her discharge delayed given the tentative indication she had received from Mr Wilkinson the day previously that her discharge would be in order and given too that her mother had arrived and was ready to drive her home. The imminent arrival of family from interstate was also a reason probably given to Nurse Cowen for Mrs York's keenness to go home. However, the question is whether all of this information was relayed to Mr Wilkinson by Nurse Horak so for him to be aware of "a lot of pressure in the ward." Nurse Horak was not caring for Mrs York. She was not advised by Mrs York or her mother of those factors surrounding her wish to go home. The only information she had was that conveyed to her by Nurse Cowen. She received this information whilst she was on the phone discussing another patient with Mr Wilkinson. She says that she was only told that Mrs York was keen to go home and it was this information that she passed on. In the circumstances in which she was instructed by Nurse Cowen it is likely in my view that this was the only information given to her. I therefore find that Mr Wilkinson was only informed that Mrs York was keen to go home and nothing more. This information should not, in my view, have been capable of pressuring Mr Wilkinson so that it overly influenced his decision to permit her discharge.
40. I accept that both Nurses Cowen and Lyne were concerned that Mrs York was leaving the hospital without medical review given the observations obtained that morning and the reservations expressed by Nurse Thornley. It is likely in my view that Nurse Lyne did suggest that Mrs York not leave without waiting to see Mr Wilkinson. However, Nurse Lyne did not know when Mr Wilkinson would be attending. In any event it was Mrs York's understanding that he had given his approval for her discharge. She was unaware that he did so ignorant of the observations made by Nurse Thornley that morning. If she had been informed of these and their implications it is probable that she may have reversed her decision to leave.
Events Post Discharge
41. Mrs York left the Private at about 11.00am on 30 January in the company of her mother. They travelled to Mrs Caudwell's home at Grove, a distance of about 35 km from Hobart and arrived at about noon. That afternoon Mrs York complained of feeling unwell. She was in pain and vomiting. She developed a large lump on her stomach. In the late afternoon she took herself to the toilet. Whilst there the lump burst. It began gushing puss. Family members called for an ambulance. Whilst waiting Mrs York began to experience breathing difficulties.
42. Records from Ambulance Tasmania show that it received the first telephone call from Mrs York's family at 7.01pm. An ambulance was not available at that time to respond. A second call was made at 7.11pm. The first ambulance contacted was not available and the call was passed to a second vehicle at 7.17pm. That ambulance was dispatched at 7.21pm and it arrived at Mrs Caudwell's home at 7.40pm. It began its return journey after ten minutes and arrived at the Royal at 8.14pm. En route it met a second ambulance which had been summoned for support. An intensive care paramedic from the second ambulance joined the first and assisted with Mrs York's care until her arrival at hospital.
43. I interpolate here to observe that none of the evidence produced by Ambulance Tasmania was challenged, no contrary evidence was produced and no submissions were made critical of Ambulance Tasmania. In these circumstances I am satisfied that the service provided by Ambulance Tasmania was appropriate and that it did not, in any way, contribute to Mrs York's death.
44. Mrs York was admitted to the Royal, via its Emergency Department, at about 8.30pm on 30 January 2010. Her condition continued to deteriorate. At about 11.00pm Mr Wilkinson commenced an emergency laparotomy. It revealed widespread peritonitis and a small perforation of the stomach. It was repaired. Mrs York's condition did not improve. It in fact worsened. She died, despite intensive care life support, at 1.00pm on 31 January 2010.
45. Dr Donald Ritchey is a forensic pathologist. He carried out an autopsy on Mrs York on 1 February 2010. He determined the cause of her death to be sepsis with multiple organ failure. Dr Ritchey further reported that Mrs York's sepsis was due, in his view, to a perforation of the stomach which occurred during the gastric laparoscopic band replacement.
The Cause of Death
46. Dr Ritchey's opinion that Mrs York died from sepsis with multiple organ failure is incontrovertible. The issue for consideration is the source of the infection which led to the sepsis.
47. It is clear that the sepsis detected by Dr Ritchey at post-mortem was widespread and well developed, he observing that "it fully involved the entire peritoneal cavity" and "had been going on for a period of days." Mr George Hopkins, a surgeon who gave evidence at the inquest, made comment that when Mrs York was re-admitted on 30 January "she had seropurulent discharge coming from the laparoscopic wounds, which essentially means she was bursting with toxicity." It was Mr Hopkins' further opinion that it "stretches credibility" to suggest that such an infection might occur spontaneously. Instead it was his firm view that the infection was the consequence of a perforation of the bowel or of the stomach and was related to the gastric banding procedure. He stated his opinion in these terms; "Whether it's clear or not what the cause was, there had to be a cause nobody has findings like that at laparotomy and subsequent autopsy without an underlying cause. … it's not a normal finding at laparotomy or indeed at autopsy, so the most common cause faraway is a perforated viscus, meaning any hollow organ being perforated. A major inter-abdominal catastrophe such as has been evidenced in this terrible outcome has a cause and I just - I'm not going to tell you what the cause was, but if you lined up 99 specialists like me 99 would say there was a perforated viscus." He went on; "If you have an operation within the abdominal cavity and some days later there's gross contamination of the abdominal cavity the two are related." In a similar vein Dr Ritchey says; "The temporal relationship between the laparoscopy and the manifestation of the major infection and the findings of laparotomy on 30 January suggest the laparoscopy caused the infection, regardless of what the specific cause might have been."
48. In my view it is logical to draw a connection between Mrs York's gastric banding procedure and her subsequent grossly advanced sepsis presenting just 10 days later and this is particularly so when no other plausible explanation has been proffered. However, it is a difficult task to identify the actual causative event, associated with the gastric banding, which led to the infection. Mr Hopkins observed that the procedure employed by Mr Wilkinson in placing the gastric band was "standard" and he made no criticism of it. He had viewed a video of Mrs York's operation and said; "I see no demonstrable source of iatrogenic trauma to the anatomy." He thus concluded that its "almost (certain) the injury took place outside the field of the scope."
49. At post-mortem Dr Ritchey noted a suture in the stomach which Mr Wilkinson had made during the emergency laparotomy. This led to Dr Ritchey opining that Mrs York's sepsis was attributable to a perforation of the stomach at that site and which had occurred during the gastric band placement. Mr Wilkinson's has confirmed that he made the suture at the time of the emergency laparotomy to repair a "pinhole" which he detected in the front of the stomach. It was his further evidence that at the time he noted "5 or 10 mils of fresh gastric fluid" in the immediate area of the hole which indicated to him that it was an acute perforation "that had occurred just prior to her (emergency) laparotomy." It was his view that this may have occurred during attempts to resuscitate Mrs York at the time of her emergency admission to the Royal. One alternative, he said, was that "the resuscitation may have caused a split in an area of the stomach that had become thinned and adherent." Another possibility was that the prolonged resuscitation caused a plication suture, which had been inserted as part of the gastric banding procedure, to pull out and cause a tearing of the stomach. Interestingly, this latter option was mentioned for the first time when Mr Wilkinson gave evidence and had not previously been suggested as an explanation for the hole in Mrs York's stomach in any of the three written reports which he provided prior to the inquest.
50. It is not possible for me, on the evidence, to dismiss Mr Wilkinson's opinion that the hole observed by him at the time of the laparotomy may have been attributable to a recent occurrence related to the resuscitation. This being so, I am unable to make a positive finding that the hole in the stomach and sutured by Mr Wilkinson was the cause for the abdominal infection as opined by Dr Ritchey following his autopsy. Of course, if any such hole was attributable to the resuscitation then it could not have been the source of the infection which led to Mrs York's death because the evidence to which I have already referred shows that at that time the infection was particularly advanced.
51. Dr Ritchey, in his evidence agreed, absent a perforation of the stomach, that it was a reasonable hypothesis to suggest that there was a perforation of the bowel brought about by a nicking of that organ during the lap-banding procedure. However, he acknowledged that a specific perforation of the bowel was not seen at autopsy. Mr Wilkinson considered it unlikely that an injury to the bowel could have occurred in this way because of the particular surgical technique which he employed. Rather, he suggested this scenario to possibly explain an association between his surgery and the sepsis; "…….to be truthful I don't know what the cause of her sepsis was, but if I had to list the possibilities I would say that given her presentation with chest signs, she may have had a leak develop near the band over the few days after she went home, and that's led to mediastinitis, which has subsequently spread to the abdomen."
52. I accept the opinions of Mr Hopkins and Dr Ritchey that Mrs York's sepsis was a consequence of the gastric banding procedure. This is a logical conclusion given their temporal relationship. The evidence does not permit me to make a finding on the precise source or cause of the sepsis. However, it was in all likelihood attributable to a perforation of the bowel or the stomach either occurring at the time of the gastric banding procedure or evolving at a later time as a result of trauma inflicted upon either the stomach or the bowel during the course of that procedure.
The Adequacy of the Medical Care
53. Dr Peters was the first medical practitioner to attend Mrs York when she re-presented at the Private on 26 January. She obtained a history which she documented and which included reference to the recent gastric banding. She undertook a clinical examination (not including an examination of the abdomen) and recorded the results. In a report provided to the coroner Dr Peters describes the initial diagnosis made by her on 26 January in these terms; …..sepsis due to post-operative complication of aspiration of pneumonia or perforation. She was also dehydrated. She had a moderate risk of pulmonary embolism (PE)…." Nowhere in the ED records does Dr Peters make express reference to a diagnosis of sepsis or to perforation and I suspect her report was influenced by a retrospective element. Nevertheless, the investigations which she did initiate, including the abdominal x-ray, were directed at the possibility of abdominal sepsis. Dr Peters' examination and the results of the investigations did warrant Mrs York's presentation being reported to Mr Wilkinson and Dr Peters took this step. She then implemented his instructions. Overall, it is my view that Dr Peters' actions were appropriate and most certainly do not permit a finding that she contributed to Mrs York's death.
54. Before considering aspects of Mr Wilkinson's care of Mrs York I need first to refer to the evidence of Mr Hopkins. I have referred to him earlier. He is a surgeon and has been a Fellow of the Royal Australian College of Surgeons since 1999. He is currently employed at the Royal Brisbane Hospital. His sub-speciality is upper gastrointestinal surgery and for the last 5 years 90% of his practise has involved weight loss surgery. He assisted this inquest by providing reports and appearing to give evidence. Mr Hopkins expressed these relevant opinions in an exchange with counsel:
Counsel: "And (Mr Wilkinson) was making investigations which were designed to determine whether that was the source of the sepsis or whether the chest was the source of the sepsis?"....
Mr Hopkins: "Well, I'm a bit unsure. When you say he was making investigations, apart from the admission CT scan, which was deemed to be prohibited due to her shortness of breath and her unwellness, her retching, I'm not sure what else was done to make my point, that I do agree with Mr Wilkinson's suggestion that investigation and management of complications in the supine obese can be very difficult indeed. But that is what leads me to the opinion that repeat laparoscopy is the best - almost the only route to go down because there's nothing else. If you're not CT scanning them there are no other investigative regimes that would yield a result."
Counsel: "But there was no suggestion in the clinical signs, was there, that there was abdominal sepsis? The matters we just went through?" ……
Mr Hopkins: "I disagree. No - I disagree. She was screaming abdominal sepsis. She had a pulse rate unexplained, a temperature seemingly through the roof. I mean, if you go back to the admission notes of the readmitting lady whose name I can't remember - I think it was Sonya Peters - on the front page - I mean, her provisional diagnosis was intra-abdominal sepsis, and look, again I do apologise because I read this in retrospect, but to me, all the indicators were that she had intra-abdominal sepsis."
Counsel: "Yes, in retrospect, and no doubt, nobody would quarrel with that, surely?
Mr Hopkins: "Well - yeah, I can see your point, but again someone with an unexplained tachycardia, white cell count, CRP, as a general rule that's an intra-abdominal problem evolving and attempts to diagnose other conditions were made but none of which were really convincing that all those abnormal parameters - and I say abnormal and getting more abnormal, that's what bothers me the most, to be honest. It wasn't just that they were abnormal but as I explained to Mr Jackson - or he explained to me and I agreed with him, they seemed to be getting more abnormal with time, not less abnormal. That's what bothers me the most."
Counsel: "If there had been a laparoscopy on one of those days that you¡¦ve suggested, what would you expect to have been found, given what you now, know, of course?"......
Mr Hopkins: "Well, I expect we would have found the earlier stages of what we found at autopsy to be an end stage problem, and that would have been intra-abdominal sepsis."
55. It was apparent from the outset that Mrs York was suffering from an infection or inflammation with its likely source being either the abdomen or the chest. In Mr Wilkinson's view the problem was chest related and atelectasis was his working diagnosis and this was maintained up to discharge. The course of treatment implemented by Mr Wilkinson was inpatient observation coupled with a course of intravenous antibiotics. No further investigations were pursued apart from a leg ultrasound and a second chest x-ray. Notably a laparoscopy/laparotomy was not performed to exclude the possibility of an abdominal infection. Mr Wilkinson permitted Mrs York's discharge on 30 January when he was ignorant of the observations made by Nurse Thornley in the early hours of that morning. I make these observations:
Mrs York's presentation at the ED on 26 January was 5 days post gastric banding surgery. She clearly had an infection. The majority of her symptoms and signs related to the abdomen. These circumstances made it a real possibility that Mrs York was suffering from abdominal sepsis and the investigation of this likelihood should, in my opinion, have been the focus of Mr Wilkinson's management.
CT scanning of Mrs York's abdomen was not possible as her gross body size made her too large for the scanner. A laparoscopy/laparotomy was therefore the only means of either excluding or confirming the abdomen as the source of her sepsis.
In my view Mrs York's history and her presentation on 26 January required this diagnostic procedure to be carried out without delay. If it had been it is likely that her sepsis would have been detected and curative steps initiated.
The clinical charts clearly demonstrate an on-going infection with a deterioration in Mrs York's condition in the days following her re-admission despite the administration of intravenous antibiotics. These circumstances, in my view, required a re-assessment of Mrs York's management. In particular, it should have alerted Mr Wilkinson to the possibility that his diagnosis of atelectasis was incorrect and that her abdomen may be the source of the problem. This should have reinforced in his mind the need for its investigation by laparoscopy or laparotomy.
When Mr Wilkinson last saw Mrs York at 11.30 am on 29 January her last recorded pulse was 145bpm with a graph showing a steadily decreasing blood pressure since admission. At this time the chart also showed temperature spikes of 38.9 and 38 degrees in the preceding two days. Too, the chart showed falling oxygen saturation levels with a reading of 97% on 27 January declining to 91% in the morning of 29 January. In my view, these signs clearly showed Mrs York to be seriously unwell and her discharge the following day should not have been in contemplation.
Mr Wilkinson's decision to permit Mrs York's discharge on 30 January was, as he now acknowledges, an error of judgement. The seriousness of his error was compounded by his failure to be advised of the observations obtained by Nurse Thornley that morning. Those observations clearly showed a further deterioration in Mrs York's condition making her discharge totally inappropriate.
The Nursing Staff
56. Nurse Cowen was responsible for Mrs York's care on 30 January. In my view the level of care provided by her was deficient. She was aware that Mrs York was hopeful of being discharged home that morning. She was also aware from the morning's handover of the latest observations made by Nurse Thornley and that they had been recorded as a variation in the records. Too, she knew of Nurse Thornley's concerns that Mrs York may not be sufficiently well to go home. Nurse Cowen should have appreciated that it was critical, if Mr Wilkinson was to make an informed decision upon Mrs York's discharge, that he be informed of these matters and that he be aware of her current status. This required Nurse Cowen to take a further set of observations before communicating with Mr Wilkinson. This did not occur. Further, when Nurse Horak spoke to Mr Wilkinson, Nurse Cowen did not ensure that she informed him of the observations taken by Nurse Thornley and her concerns. In the result Mr Wilkinson made the decision to authorise Mrs York's discharge, a decision which was ill-informed, ill-considered and incorrect. Nurse Cowen's omissions contributed to this erroneous decision.
Findings Required by S28(1)(a) - (e) of the Coroners Act 1995.
57. I formally find that Mrs Joanne Jean York died on 31 January 2010 at the Royal Hobart Hospital in Hobart. Mrs York was aged 26 years having been born on 24 May 1983. She was married to Robert Lawrence York and resided at Geeveston. The cause of Mrs York's death was sepsis with multiple organ failure. The sepsis was a consequence of a gastric banding procedure performed upon Mrs York 10 days prior to her death.
Contribution to the Cause of Death
58. By s28(1)(f) of the Coroners Act 1995 I am required, if possible, to identify any person who contributed to Mrs York's death. Obviously a finding that a medical practitioner or nurse has contributed to a patient's death should not be made lightly and needs to be firmly established by the evidence. In my view the test formulated by the High Court in Briginshaw v Briginshaw (1938) 60 CLR 336 is apt and should be applied. It was stated by Dixon J at 362-3 in these terms;
"….reasonable satisfaction is not a state of mind that is attained or established independently of the nature and consequence of the fact or facts to be proved. The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer to the question whether the issue has been proved to the satisfaction of the tribunal. In such matters "reasonable satisfaction" should not be produced by inexact proofs, indefinite testimony, or indirect inferences…."
59. I need to consider whether a finding of contribution should be made against Dr Peters, Nurse Cowen and/or Mr Wilkinson.
60. For reasons explained above, (para. 53) I do not believe a finding of contribution should be made against Dr Peters.
61. I now turn to Nurse Cowen. In the morning of 30 January Mrs York was seriously unwell and should not have been discharged. Nurse Cowen, by omissions on her part, did not ensure that Mr Wilkinson was fully informed of Mrs York's state of health when his permission was sought for her discharge. His decision to allow her to go home was wrong. Did Nurse Cowen, by enabling this decision, contribute to Mrs York's death? The answer to this question requires the answer to another; ie. is it probable that Mrs York's death from sepsis would have been avoided if she had not been discharged in the morning of 30 January?
62. It was the evidence of Dr Ritchey that if Mrs York was to survive her sepsis intervention by way of a laparoscopy needed to occur "days earlier than it did." In a similar vein these exchanges took place between counsel and Mr Hopkins;
Mr Hopkins: "In my hands early laparoscopy would have almost certainly diagnosed this problem in its earlier phases and more than likely I think if she'd been laparoscoped in three to five days she wouldn't have died."
Counsel: "And you'd agree that really in this case for any reasonable chance of survival any intervention needed to be days earlier than what occurred?"......
Mr Hopkins: "Absolutely, yep."
Counsel: "And in your evidence when you were being led in your evidence by Mr Jackson you said that it was more likely than not that if she was laparoscoped within three to five days she would not have died. Now that three to five days is three to five days following the laparoscopic surgery on the 21st of January? …..
Mr Hopkins: "Yes."
63. Mrs York's survival was dependent upon the early diagnosis and treatment of her abdominal sepsis. As Mr Hopkins said; "the earlier the better." In Mrs York's circumstance her diagnosis could only be made and treated by laparascopy/laparotomy. Had Nurse Cowen ensured that Mr Wilkinson was fully informed of Mrs York's state of health in the morning of 30 January then I accept that he would not have permitted her discharge. Sometime later that day it's likely that Mr Wilkinson would have re-examined Mrs York. What plan he would then have put in place for her on-going care is not known. However, if he then determined to proceed with a laparascopy or laparotomy this would not have taken place until some time that afternoon at the earliest, that is 9 full days after the gastric banding surgery. The evidence of Dr Ritchey and Mr Hopkins, which I have set out above, makes it clear that Mrs York's best prospects of survival required a laparoscopy to be carried out within 3 to 5 days of her initial surgery. Given this evidence I cannot be satisfied that Mrs York's life would have been saved if this procedure had taken place in the afternoon of 30 January. In fact the evidence that she failed to survive after the emergency laparotomy done that same evening is suggestive that by the afternoon of 30 January the time had passed for her successful rescue. It follows that a finding that Nurse Cowen contributed to Mrs York's death by her role in her discharge should not be made.
64. Mr Wilkinson resumed responsibility for Mrs York's care in the afternoon of 26 January and he remained responsible for her care up to the time of her discharge 4 days later. Did his care during that time contribute to the death?
65. When Mrs York presented at the ED on 26 January she was clearly suffering from an infection. Initial investigations suggested its source to be either the abdomen or the chest. Mr Wilkinson favoured the latter and atelectasis became his working diagnosis. His care plan was confined to impatient observation with intravenous antibiotics. Mr Wilkinson did not, from the time he made his diagnosis initiate any steps to further investigate the abdomen as the possible source of Mrs York's infection.
66. Many of Mrs York's signs and symptoms were consistent with abdominal sepsis when she was re-admitted to the Private. They were so evident to Mr Hopkins to warrant his description that Mrs York was "screaming abdominal sepsis." Notwithstanding his working diagnosis, it is my view that Mr Wilkinson should have continued to investigate the possibility of the abdomen as the source of the infection. This is because abdominal sepsis may be a fatal condition which progresses rapidly. Its early diagnosis and treatment is vital if death is to be avoided. When Mrs York presented at the ED she was already five days post-surgery. In my view, the further investigation of the abdomen necessitated a laparoscopy or laparotomy and this should have been carried out on either 26 or 27 January. Had this been done there is in my view a very real likelihood that the sepsis would have been evident and lifesaving treatment commenced. By not carrying out the laparoscopy/laparotomy at that time Mrs York was denied her best chance of survival.
67. In my view the need for the investigation of the abdomen as the possible source of Mrs York's infection became even more apparent as her inpatient stay progressed. I have set out above detail of Mrs York's clinical chart which clearly maps the deterioration in her condition notwithstanding the administration of intravenous antibiotics. Of particular note is the oscillation in her temperature coupled with an ascending pulse and declining oxygen saturation levels. When Mr Wilkinson attended Mrs York in the morning of 29 January a reading of her clinical chart should have told him, and he perhaps should have realised it previously, that his care plan for Mrs York was not working and that the abdomen may indeed be the source of her problem. This in turn should have led to him carrying out a laparoscopy/laparotomy which undoubtedly would have revealed sepsis in the abdomen and initiated treatment.
68. To summarise. Mr Wilkinson made a mistake in diagnosing atelectasis. He also erred in not carrying out a laparoscopy/laparotomy at the earliest opportunity to investigate the possibility of abdominal sepsis. Further, despite evidence indicating the deterioration in Mrs York's condition Mr Wilkinson did not investigate the possibility of abdominal sepsis by laparoscopy/laparotomy during the entire period of her admission. When the emergency laparotomy was eventually carried out on 30 January Mrs York's sepsis was so advanced that her life could not be saved.
69. In the above circumstances the question becomes whether Mr Wilkinson contributed to the cause of Mrs York’s death? That cause, as I have found, was sepsis with multi-organ failure. The sepsis was a consequence of the gastric banding procedure. Sepsis, as I have already observed, can be a fatal condition. It progresses rapidly. Mrs York’s best chance of surviving her sepsis was for its immediate diagnosis and treatment. This required a diagnostic laparoscopy to be carried out, preferably on 26 January but at the latest the next day. By electing not to take this course Mr Wilkinson denied Mrs York her best chance of avoiding death. Over the following days Mrs York’s prospects progressively diminished. However, there remained a chance of survival perhaps persisting to as late as 29 January. Mr Wilkinson did not during this period carry out a diagnostic laparoscopy and the sepsis was therefore not detected and hence not treated. Mr Wilkinson’s failure to undertake this procedure in this period therefore denied Mrs York any remaining chance of survival. The foregoing satisfies me to the standard required that Mr Wilkinson did contribute to the cause of Mrs York’s death.
70. S28(2) of the Coroners Act 1995 obligates me to make recommendations, most particularly with respect to ways of preventing further deaths. On this subject Mrs York's family has made some helpful suggestions. They are set out in a letter and are in these terms:
"The Hobart Private Hospital is to have in place a system which ensures:
1. The treating surgeon or if for any reason he or she is unavailable another suitable surgeon see his or her patient who presents at the Hospital following surgery with apparent complications as soon as practicable;
2. Doctors who visit their patients in the hospital record details of the visit in the patient's medical notes;
3. That nursing staff are adequately trained and experienced to recognise signs or symptoms indicating a patient's deteriorating condition;
4. That those patients receive immediate medical attention either by the treating doctor or, if he or she is unavailable, by another suitable medical practitioner;
5. That the nursing handover take place at the patient's bedside and details of it be recorded in the patient's notes;
6. The vital signs of a patient be taken and recorded shortly prior to his or her discharge;
7. A patient not be discharged without first seeing his or her treating doctor or if for any reason he or she is unavailable another suitable doctor unless the patient signs an appropriate waiver form;
8. The treating nurse fully appraise the treating doctor prior to discharge of the current health status of the patient including his or her current vital signs and that this process be documented in the patient's notes at the time."
71. The foregoing all, in my view, represent sensible standards. In several instances they duplicate recommendations made by me in a previous coronial finding involving the Private. (Frances Proposch-Quarrell died 6 July 2004) I am advised by the Private's counsel that in most instances the standards set out above are incorporated in the hospital's current policy documentation. Some existed at the time of Mrs York's death and others have been added subsequently. Of the additions most notable is the introduction of a tool, known as iSOBAR, which is designed to be used in conjunction with an Adult General Observation AGO sheet. The purpose of this dual documentation, it was said, is to assist nursing staff by a system of colour coding to identify from a patient's clinical chart a deterioration in the observations and the point at which medical intervention should be sort. Interestingly, if this had been in use at the time of Mrs York's admission her observations made by Nurse Thornley in the morning of 30 January would have mandated immediate medical attendance. The adoption of this documentation is clearly a step forward and it is to be hoped will go some way in avoiding the catastrophe which befell Mrs York.
72. I adopt and support the standards for care set out in the family's letter. However, it is not enough to prescribe standards and for them to be incorporated in a hospital's policy documentation. More critical is to ensure that those persons to whom the policies apply are familiar with their content and comply with it. It is my recommendation that the Private takes steps to ensure that this occurs and that it regularly audits compliance by its own staff and those other health professionals including surgeons who utilise their facilities.
I conclude by extending my sincere condolences to Mrs York's husband, children and family for their loss.
Dated in Hobart this 25th day of February 2013.