Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

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

Elwyn Aubrey Bailey


Find :

(a) Elwyn Aubrey Bailey ("Mr Bailey") died on 5 December 2008 at the Hobart Private Hospital ("HPH") in Hobart.

(b) Mr Bailey was born in Launceston on 28 February 1932 and was aged 76 years. He was married and retired.

(c) I find that Mr Bailey died from the combined effects of pancreatitis and ischaemic heart disease. A possible contributing factor was a high therapeutic level of pethidine.

(d) At the time of his death Mr Bailey was in the care of a medical practitioner at the HPH.

Circumstances Surrounding the Death :

Mr Bailey’s past medical history included ischaemic heart disease, haemochromatosis, cholelithiasis, type II diabetes, gout, hypertension, depression (post cardiac surgery), mitral valve repair and meningioma. In 2005 he underwent triple bypass surgery. He also had a history of heavy alcohol consumption. In July 2008 he was hospitalised in Queensland with pancreatitis after which he ceased drinking alcohol.

During the evening of 4 December 2008 Mr Bailey was suffering from right upper quadrant/epigastric pain. He was taken by ambulance to the Emergency Department ("the ED") of the HPH arriving at 10.25pm. At this time the ED was staffed by Dr David Fitzgerald and Registered Nurse Stephen Rae. A ward clerk was present but her duties were largely confined to clerical tasks.

Dr Fitzgerald assessed Mr Bailey as being haemodynamically stable with a tender, but soft abdomen. He believed that Mr Bailey was suffering from cholelithiasis (gall stones) or pancreatitis. Dr Fitzerald admitted Mr Bailey to the Short Stay Unit ("the SSU") with the intention that he would be admitted to a ward the following morning and be examined by a gastroenterologist.

The ED records show that clinical observations of Mr Bailey were made at 10.25pm, 11.50pm and 1am. Nurse Rae reports that he made a further observation at 2.00am although this time is not legible from the records. Mr Bailey was assessed as sleeping comfortably from 1.40am to about 3.20am on 5 December with "good rise and fall of chest, snoring."

At 5.20am Mr Bailey was found unresponsive. He was transferred to the resuscitation area where he was intubated and CPR was performed. However, all resuscitative efforts failed and Mr Bailey was declared deceased at 5.36am on 5 December 2008.

A post-mortem examination was undertaken by State Forensic Pathologist, Dr Christopher Lawrence. Toxicology tests revealed ‘a high therapeutic pethidine level (0.7mg/L) and 00.9 mg/L of morphine.’ Dr Lawrence notes that ‘It is difficult to interpret the significance of this result. There may be some post-mortem redistribution of pethidine. The presence of the other drugs and the presence of cirrhosis of the liver further complicate this assessment.’ In Dr Lawrence’s opinion the cause of Mr Bailey’s death was the combined effects of pancreatitis and ischaemic heart disease. He considered that a high therapeutic level of pethidine may have contributed to the death.

A review of the HPH records show that Mr Bailey received the following medications:

  •  Morphine: 2.5 mg IVI at 22.50, 22.55, 23.15 and 23.25,
  •  Morphine: 10 mg sc at 00.10,
  •  Metoclopramide: 10 mg IVI at 22.50,
  •  Buscopan: 20 mg in IV fluids at 22.50,
  •  Pethidine: 100 mg IMI at 01.40 and
  •  Temazepam: 20 mg O at 01.40.

At the time of Mr Bailey’s death, Dr Stephen Ireland was the Acting-Director of the ED. He was the person responsible for all persons admitted to the SSU. He was not informed of Mr Bailey’s admission and only became aware of his death that morning. He has expressed the following concerns related to the circumstances of Mr Bailey’s death:

  • "….firstly there was an overload of work for the nursing staff member. This arose from shortages of nursing staff and the nurse who volunteered to do the night shift did this out of conscience as he had already worked a day shift but knew if no-one volunteered to do the night shift the ED would have to go on ambulance bypass which the hospital had been trying very hard to avoid due to the adverse publicity it attracted."

  • When Mr Bailey was placed in the SSU, the "decision should have been made to go on ambulance bypass as it is not feasible to maintain observations on patients in the Unit and in the other cubicles safely with only one nursing staff on duty." This decision was the responsibility of the doctor on duty and the Nursing Supervisor overnight in conjunction with management.

  • Because ambulance bypass was not initiated patients continued to present to the ED including "one in particular (who) needed fairly intensive care which may have been a distraction from Mr Bailey’s care."

  • "…..Mr Bailey should not have been placed in the SSU because he had received a lot of narcotic to control his pain, some of it intramuscular with unpredictable absorption in his state and his significant co-morbidities……..On top of this he received oral sedation to settle and once again with the delayed effect of the intramuscular narcotic on top of the already administered intravenous narcotic there was a risk of unknown respiratory depression on a frail patient."

  • "Normally we would keep these patients under close supervision near to where the staff can observe them rather than in the slightly physically remote Short Stay Unit."

  • He says that he does not have any concern over the amount of narcotic administered "as he had considerable pain" but "I do have concern about intramuscular narcotics in emergency due to the delay in effect and the unpredictable time scale of absorption. Also I think that changing the narcotic was not of predictable benefit and I would have been very wary of adding any oral sedation, once again with unpredictable effect in someone of his health status and prior narcotic dosage."

  • He concludes; "In essence it gets down to the inability to effectively observe this man where he was situated, given other important distractions. He was frail and had had a significant quantity of depressant medication."

Dr Fitzgerald was employed by the HPH to work two days a fortnight in ED. A statement provided by Dr Fitzgerald provides this information upon his management of Mr Bailey:

  • He was in a degree of pain on arrival so was administered doses of intravenous morphine in 2.5mg aliquots to achieve rapid control of his pain.

  • "His blood results were unremarkable and his pain had eased in the early hours of the morning. It was decided that due to the hour in the evening, a consultant would be contacted in the morning with regards to his admission and ongoing care, rather than phone someone in the middle of the night, and in the interim he would be admitted to the short stay unit attached to DEM."

  • "He continued to have some discomfort in the RUQ, although eased, and wanting to provide longer lasting pain relief, and not wanting to tie up the nursing staff with the more intensive monitoring required by the continuous use of intravenous morphine (which would also have been much shorter in duration of action), he was administered a dose of intramuscular pethidine. He was at that time fully conscious and alert and in fact was still quite anxious and he requested a sleeping tablet, so was administered 10mg of temazepam."

  • "Around that time another quite ill patient was brought into the department by ambulance with I recall a significant respiratory illness. This gentlemen required quite a deal of attention and time on behalf of both myself and the nurse and was subsequently admitted to the high dependency unit as I recall. Necessarily, the attention given to this gentleman distracted us from the other patients in the department at the time."

  • "It was around 2am or thereabouts that the activity in the department settled down and having no ongoing issues that needed my attention, I took the opportunity to take a rest. Shortly thereafter, the nurse on doing the routine observations of the patients in the department found Mr Bailey unresponsive and blue."

  • "…after (the administration of) intravenous narcotic analgesia it is generally standard practice to observe the patient more or less constantly until such time as pain is relieved satisfactorily and the patient stabilized clinically. With intramuscular narcotics, the requirement is not so stringent as the potential for respiratory depression etc is less marked due to the longer duration of action. However in someone given pethidine, it would be standard practice for the staff to review the patient on a half hourly or hourly basis post the intramuscular dose to ensure the patient’s pain is controlled, thus necessitating further analgesia and there are no clinical adverse effects. I am however unaware of the details of any specific hospital policy on this issue".

Mr Bailey had been transferred to SSU at about 11.40pm. After this the ED continued to receive patients. Nurse Rae reports that at 3.50am on 5 December a triage category 2 patient attended with acute pulmonary oedema. This patient required one-to-one nursing by Nurse Rae for approximately one hour before transfer to the admitting ward at about 5.00am. Also, at about 4.30am a triage category 3 patient attended by ambulance with acute abdominal pain and hypertension. This patient was triaged and admitted by Nurse Rae at 4.55am and then reviewed by Dr Fitzgerald at 5.10am.

Nurse Rae further reports:

  • That the hospital’s Nurse Coordinator was aware of the number and type of patients in the ED during his shift, and

  • The HPH has, since Mr Bailey’s death, reviewed the level of night duty staffing and has determined that the SSU will not operate without extra staffing.

Ms Mary Walker was the Director of Nursing at the HRH at the time of Mr Bailey’s death. She reports that since that time the hospital has made a policy change so that patients requiring frequent intravenous narcotics are not to be admitted to the SSU.

Findings, Comments & Recommendations :

I am satisfied that a thorough and detailed investigation has been carried out into the death of Mr Bailey and that there are no suspicious circumstances.

I accept the opinion of Dr Lawrence and find that Mr Bailey died from the combined effects of pancreatitis and ischaemic heart disease. I find too that a possible contributing factor was a high therapeutic level of pethidine.

The circumstances surrounding Mr Bailey’s care and management by the HPH, most particularly the level of observation maintained in the hours prior to death is a cause of very real concern.

I accept that at the time of his admission to the ED Mr Bailey was suffering severe pain and it was appropriate for him to be treated with narcotic medication. The records show that in the 90 minutes post-admission he received five doses of morphine, administered by both intravenous and subcutaneous injection, and 90 minutes later received a 100 mg dose of pethidine given intramuscularly. I do not make any criticism of the amount or type of analgesia administered to Mr Bailey as I accept that it was required to bring his pain under control. However, the administration of this volume of medication over a relatively short time frame to an elderly patient suffering multiple co-morbidities mandated a high level of observation. Regrettably, this degree of observation was not forthcoming. The evidence shows that Mr Bailey was administered his one dose of pethidine at 1.40am with a sedative and that clinical observations were made twenty minutes later. However, in the period between 2.00am and 5.20am when Mr Bailey was found unresponsive, he was observed on one occasion only being at 3.20am when he was noted to be sleeping comfortably. There were no observations made in the next two hours. It is my opinion that this level of observation was, in the circumstances insufficient and fell well short of the standard of care that Mr Bailey and his family could reasonably have expected.

Nurse Rae was the only nurse on duty on the night and ordinarily he would have had primary responsibility for maintaining proper observation of Mr Bailey. However, the evidence shows that after Mr Bailey was placed in SSU the ED continued to receive patients. Critically, between 3.50am and 5.00am Nurse Rae was occupied managing the care of two patients, one of whom was suffering acute pulmonary oedema and required one-to-one nursing until his transfer to a ward at 5.00am. I accept that in these circumstances it was not feasible for Nurse Rae to maintain the level of observation of Mr Bailey which his condition required, particularly in the 90 minutes preceding 5.20am.

There were in my opinion a number of steps which could and should have been taken by HPH to better ensure Mr Bailey’s safety. The first and most obvious was to allocate additional nursing staff to the ED from the beginning of the night shift. If additional nurses were unavailable it was incumbent upon the Hospital Co-Ordinator to closely monitor demands on staff within the ED and to take such steps as were necessary to ensure patient safety.

Proper monitoring on the night of 4/5 December 2008 should have shown that Nurse Rae, by himself, was unable to maintain the required level of observation needed by Mr Bailey after his admission to SSU and at the same time meet the nursing needs of other arrivals. This was particularly so when the patient suffering acute pulmonary oedema attended. Steps which could have been taken to relieve the situation, either singly or together, included placing the ED on ambulance bypass, admitting Mr Bailey to a ward, directing nursing staff from elsewhere in HPH to provide temporary assistance or fitting Mr Bailey with an oxygen saturation probe which, in the very least, would have alerted staff to a deterioration in his respiratory status.

It is noted from his statement that Dr Fitzgerald, for a period immediately prior to Mr Bailey’s death, ‘took the opportunity to take a rest." This period coincided with the time that Nurse Rae was at his busiest meeting the nursing needs of both the pulmonary oedema patient and another patient suffering abdominal pain and hypertension. If additional nursing staff was unavailable to assist Nurse Rae at this time, it would not, in my opinion have been unreasonable to have required Dr Fitzgerald to provide some assistance which could have involved him maintaining observation of Mr Bailey, at least until Nurse Rae was free to resume this task.

I have found that the level of observation afforded to Mr Bailey whilst he was in SSU fell well short of the level that his circumstances required. Whilst I cannot make a positive finding that Mr Bailey’s death would have been avoided if a more diligent observation regime had been in place, I am nevertheless of the firm view that the existence of such a regime would have very significantly enhanced the likelihood of his declining condition being detected and life-saving measures taken.

I conclude by extending my sincere condolences to Mr Bailey’s family. 

Dated: Tuesday 17 May 2011 at Hobart in Tasmania.

Rod Chandler