Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Glenn Alan Hay, Coroner, having investigated the death of
Dorene May Cracknell
WITHOUT HOLDING AN INQUEST
Find:
(a) the identity of the deceased is Dorene May Cracknell (Mrs Cracknell), born in Sydney on 27 February 1929, a married woman whose occupation was home duties;
(b) Mrs Cracknell died as a result of head injuries, sustained by her in an unwitnessed fall from standing height, in her bedroom at the St John’s Campus of Calvary Healthcare;
(c) the cause of her death was subdural haematomas from a closed-head injury influenced by partial paraplegia from complicating spinal cysts and stroke;
(d) Mrs Cracknell died on 30 July 2008, in the Intensive Care Unit (ICU) of the Royal Hobart Hospital (RHH);
(e) no other person contributed to the cause of her death;
(f) at the time of Mrs Cracknell’s death she was being treated by a medical practitioner.
Circumstances:
On the 14 July 2008 Mrs Cracknell was admitted to the rehabilitation ward at St John’s Hospital (Calvary Healthcare) for intensive care rehabilitation following paraplegia that occurred intra/post surgery in 2006. Upon her admission a ‘falls risk assessment’ was carried out by nursing staff and she was assessed as being of ‘medium risk’. As a result of the assessment treatment protocols were established for her care, including the following:-
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Discuss falls risks with patient and family
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Consider the need for additional lighting
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Assist/supervise patient when transferring/walking
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Communicate risk status to all staff involved in patient care
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Check patient regularly
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Toileting needs to be assessed every two hours while the patient is awake
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Initial referral to clinical pharmacist completed or re-refer if medications changed
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Request VMO referral to physio if not previously activated.
Medical records indicate that Mrs Cracknell’s ‘falls risk’ was reassessed and downgraded to ‘low’ sometime after her initial assessment, possibly on the 21 July 2008, but the record is undated. It is incongruous that the second assessment on matters such as her vision and continence would be downgraded as these would have presumably remained unchanged, particularly, for instance, given that she had a permanent suprapubic urinary catheter in situ that was not removed during her admission.
However, I note that Mrs Cracknell’s daughter, Virginia Hargrave made the following comment regarding her mother’s admission, ‘…she made very good progress and was doing well. She had physio twice a day most days. She could do most things by herself and was allowed to go to the toilet and get out of bed by herself and everything. The only thing she couldn’t do was put her own shoes on.’
Mrs Cracknell fell in her bedroom near the bathroom door on 21 July 2008 at some time prior to 5pm. At the time she was wearing socks (and no shoes) on her feet. She may have lost consciousness for a short period before being assisted back to bed by visitors from an adjacent room who heard the fall around 5pm.
Dr Slatyer, her rehabilitation physician, attended her at 5.45pm when Mrs Cracknell appeared alert and orientated. Dr Slatyer ordered bed rest, paracetamol and four hours of neurological observations.
She was checked by a nurse and at 6.20pm her clinical observations were satisfactory.
At 6.30pm her condition was noted as deteriorating. At that time a visiting consultant, Dr Dunbabin, reviewed her condition and directed her to be urgently transported to Calvary Hospital’s Emergency Department and arrangements be made for a CT scan of her brain and neck. Her medical records indicate that while awaiting that transport she was noted to be agitated. She was also given sublingual glyceryl trinitrate to lower her blood pressure with mild effect.
Tas Ambulance Service (TAS) arrived at 6.40pm (apparently incorrectly recorded in the TAS records as 7.40pm). A TAS officer noted her condition to be deteriorating and she was conveyed to Calvary Hospital Emergency Department, arriving at 7.20pm where Drs Slatyer and Spilling were in attendance to assess her. Mrs Cracknell’s condition continued to deteriorate with Dr Slayter noting at 7.30pm that since he had last seen her, her headache intensity had increased, she was less able to be roused, she was nauseous and her blood pressure was fluctuating. A provisional diagnosis of closed-head injury was made. She was accompanied to an urgent CT scan by Dr Slayter at 8.15pm.
The CT scan of her brain became available at 8.50pm and showed extensive subarachnoid and subdural blood inter-cranially. The most prominent subdural blood is seen about the right temporal region. No cervical spine fracture is seen. Dr Spilling noted that Mrs Cracknell needed an urgent neurosurgical review. In consultation with Dr Slayter immediate arrangements were made for her to be transferred to the Royal Hobart Hospital. Dr Slatyer’s medical notes at the time indicate - ‘Things are getting serious. Transfer patient to RHH by Tas Ambulance. Will need intubation.’
At 9pm Mrs Cracknell was unresponsive and according to Calvary Hospital notes, Dr Spilling inserted a second IV line and intubated her at 9.05pm in preparation for transport to the RHH. Those notes are unclear and it is possible Dr Spilling hand ventilated his patient with a bag and mask rather than performing an intubation. By this time a TAS ambulance had arrived and the TAS report states that at 9.06pm "Dr asked if we could intubate the patient, patient was intubated by TAS. ETCO 2 high on intubation, tube checked and tested, check by Calvary A&E doctor……5 – 7 minutes after intubation patient had blood from tube / bleed, changed set and changed tube. Provisional ambulance diagnosis – Resp. arrest [indecipherable] bleed [indecipherable]…".
At 9.16pm the intubation was again checked with no sign of a bleed.She left Calvary Hospital in the ambulance around 9.30pm, accompanied by Dr Slayter and assisted by Tasmania Police.
Upon her arrival at the RHH another urgent CT scan of the brain was completed along with an angiogram. As a result of these tests Mrs Cracknell was transferred urgently to theatre for a decompressive craniotomy commencing just prior to midnight on 21 July. During the operation a very large acute subdural haematoma was removed and her brain satisfactorily decompressed. Mrs Cracknell was then taken to the ICU for after-care.
I have considered the medical notes of the RHH ICU registrar caring for Mrs Cracknell. He states that the anaesthetic registrar on re-intubating Mrs Cracknell prior to surgery commented that s/he observed a traumatic ‘hole’ in adjacent tissue and blood in Mrs Cracknell’s naso-gastric collection bag. There is a query in the notes as to whether she had had a previous traumatic intubation by the TAS paramedics. The anaesthetic registrar did not directly document these obviously important observations or queries. I find this failure concerning.
Later that day a post-operative CT scan of the brain indicated that the surgery had successfully removed the right frontotemporal acute subdural haematoma, however it also revealed the presence of a new posterior temporal acute subdural haematoma contralateral to the previous surgery. This required urgent craniotomy surgery which successfully removed a large haematoma from the left hand side. A post-operative non-contrast scan indicated a significant reduction in the left temporoparietal subdural haematoma with no evidence of bleeding on the right side.
Although Mrs Cracknell’s post-operative intracranial pressure remained unchanged she was unable to open her eyes or obey commands. She remained deeply unconscious despite aggressive treatment in the ICU.
A CT scan of the brain on 29 July 2010 demonstrated no presence of blood, but according to the Radiologist it raised the possibility of further cerebral oedema around the fourth ventricle and the cisterns in the basilar region which indicated increasing oedema or possible infarction. A possible small aneurysm in the region of the left carotid syphon was seen during a CT angiogram of the brain but to confirm this finding the Radiologist suggested a formal four vessel angiogram.
Despite aggressive treatment in the ICU and no evidence of further post-operative bleeding Mrs Cracknell did not make any further progress, remaining deeply unconscious despite the absence of sedation or any medication which itself may alter her conscious state. No neurological recovery was noted on her medical charts between the 21 and 29 July.
On 29 July further neurological deterioration was observed by the Neurosurgical Team and the Intensivist noted difficulty in maintaining systolic blood pressure and poor neurological recovery despite the absence of sedation. On that evening a CT scan of the brain showed further tight brain, indicative of a poor outcome and significant damage done by the primary haemorrhages. At about 11.00pm the on-call Neurosurgical Registrar, the Intensivist and Mrs Cracknell’s family met with all evidence presented, including the difficulty with the current treatment and the very poor neurological findings.
On 30 July a repeat neurological examination showed bilateral cerebral posturing consistent with mid brain dysfunction. These findings were also discussed extensively with the family by the Neurosurgeons and Intensivists. During these discussions it was indicated that there was no evidence that further neurosurgical treatment or treatment in the ICU would alter or improve Mrs Cracknell’s condition. In consultation with Mrs Cracknell’s family a palliative care approach was initiated.
Later that day Mrs Cracknell was extubated and passed away while in the ICU at about 7.25pm.
Comments & Recommendations:
Mrs Cracknell was a 79 year old married woman at the time of her death on 30 July 2008. She died as a result of complications from initial head injuries she suffered when she fell in her room at the St John’s Campus of Calvary where she was a patient at the time.
I consider that there has been some underestimation of Mrs Cracknell’s ‘falls risk ‘ assessment while a patient at St John’s. While there is no evidence to suggest that the downgrading of the initial ‘falls risk’ assessment completed some days after Mrs Cracknell’s admission was directly causative of her death, there was potential for problems to arise. I recommend that the St John’s Campus review their procedures associated with completing a ‘falls risk’ assessment. This matter may serve as a reminder that the use of these tools in measuring a likely risk occurring are fundamental indicators of potential problems. I also recommend that the accuracy of daily patient treatment records be more closely monitored.
I have concerns about the number of intubations carried out on Mrs Cracknell prior to her surgery and the probability of a traumatic intubation. The medical records available to me from all sources are somewhat confusing and brief and I would recommend more accuracy in note taking of important events in medical care by all health professionals. However, in this case I have no evidence this event may have contributed to or hastened her death as no autopsy was performed due to the request of the senior next of kin and at a time when the issue of possible perforation due to the traumatic intubation was not disclosed or known.
It appears Mrs Cracknell received timely care and intervention after her fall and the prompt attendance to assess and assist her by Dr Slatyer is notably positive.
Before I conclude this investigation, I wish to convey my sincere condolences to Mr Cracknell’s family.
This matter is now concluded
DATED : Monday 1 November 2010 at Hobart in Tasmania.