Record of Investigation Into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Glenn Hay, Coroner, having investigated the death of

Kelvin John Connor


Find :

(a) Kelvin John Connor (Mr Connor) died on 7 October 2010 at the Royal Hobart Hospital (RHH), Hobart, Tasmania, aged 70 years.

(b) Mr Connor was born in Melbourne, Victoria on 5 April 1940. He was in a long term relationship and had three children from a previous marriage.

(c) Mr Connor died as a consequence of peritonitis due to a leaking PEG feeding tube inserted to assist in feeding due to complications arising from an inoperable carcinoma of the oesophagus. He also had ischaemic heart disease which contributed to this death.

(d) There were no systems failures in any of the medical and nursing care provided to Mr Connor.


Mr Connor was a retired labourer and had lived with his current partner, Ms Andrea Page, in Tasmania since June 2006.

In January 2010 Mr Connor had an endoscopy following a couple of months of abdominal and chest pains. He had previously had two by-pass operations in 2002. The endoscopy located a tumour in Mr Connor's oesophagus. He subsequently had a PET scan to reveal the extent of the cancer and was diagnosed with inoperable oesophageal cancer.

Mr Connor underwent palliative radiotherapy in March 2010 at the Holman Clinic in Hobart. In May 2010 Mr Connor and Ms Page travelled to the Peter MaCallum Centre in Melbourne to seek a second opinion. They were informed the medical treatment Mr Connor received at the RHH was the same as would have been administered at the Centre.

During early September 2010 Mr Connor and Ms Page travelled to Vietnam for a holiday. On their return Mr Connor was very weak and tired, being only able to drink and consume small amounts at a time.


On Tuesday 21 September 2010, upon their return from Vietnam, Mr Connor and Ms Page went to the RHH where Mr Connor was admitted due to his poor health, which included dysphagia (difficulty in swallowing), vomiting and weight loss. Mr Connor remained at the RHH for six days for investigation and management of his condition during which time an abnormal heart rhythm (atrial flutter) was also investigated and treated successfully. Mr Connor's gastrointestinal issues were more difficult to treat and it was thought by treating doctors that his issues were related more to a gastric 'dysmotility' cause (where the muscles of the oesophagus and gastric system do not work properly) than to the cancer becoming more invasive.

Mr Connor was spoken to by treating doctors and a decision was made that insertion of a PEG (percutaneous enteroscopic gastostomy) tube into his stomach would be a reasonable palliative option for him. Mr Connor was then discharged and went home for a number of days.

Mr Connor was admitted back to the RHH on the 1 October 2010 and the PEG tube inserted on 5 October 2010. On return to the ward and with the commencement of feeds through the PEG tube Mr Connor complained of abdominal and back pain. He was given analgesia and the feeds were ceased for a number of hours.

The following morning Mr Connor was reviewed by the gastroenterology team. They noted that Mr Connor was feeling "OK now" but still had mild left upper quadrant pain in his abdomen. He was seen by the PEG/gastrostomy care nurse later that morning. The nurse has noted, "PEG tube flushed with warm water slowly - no pain experienced. Dietician to review and to recommence feeds slowly with blood results known. Bloods taken this a.m." The dietician reviewed Mr Connor shortly afterwards and his PEG feeds were re-commenced. The day shift registered nurse has noted, "Patient tolerating PEG feeds, nil complaints of pain… patient is comfortable."

The PEG nurse came to review Mr Connor again later in the afternoon and noted in the medical record, "Dressing changed, complaining of pain immediately after at PEG site. Hopefully will settle, has been comfortable all day. Will review again in the morning."

At 3:20am on 7 October 2010 a MET (Medical Emergency Team) call was instigated by staff that were caring for Mr Connor. Mr Connor had become tachycardic (fast heart rate), his oxygen saturations were low, and he was distressed and had an 'acute abdomen'. After assessment, treatment and discussion with Mr Connor and the medical staff caring for him it was deemed his care and management would centre on comfort measures only. At 4:00am Ms Page was contacted and informed of Mr Connor's condition and of his request not to be resuscitated. She went to the hospital and remained with him. Later that morning Mr Connor was reviewed by the gastroenterology team and appeared to be comfortable and without pain however he died at 10:00am that day.

A post-mortem examination was conducted by State Forensic Pathologist, Dr Chris Lawrence. In his opinion, Mr Connor died as a consequence,

"…of peritonitis due to a leaking PEG tube inserted for carcinoma of the oesophagus. He also had ischaemic heart disease which contributed to this death.

…He was having extreme difficulty swallowing so a decision was made to put a PEG feeding tube in. Following the PEG tube insertion, which was apparently uneventful, he complained of back and abdominal pain, deteriorated and died. The carcinoma of the oesophagus is widespread and probably terminal.

Autopsy reveals leakage around the PEG tube with peritonitis."

This case was reviewed by Dr Lawrence and Ms Libby Newman, Forensic Pathology Research Nurse. According to their subsequent report,

"It is our opinion that no further coronial investigation is required into this matter. Mr Connor's death highlights the risk involved in invasive medical procedures. Perforation of an organ or structure and leakage of liquid diet from around a PEG tube are known complications. Despite Mr Connor experiencing some pain at the PEG site initially this resolved. He was assessed by the gastroenterology medical team and twice by the PEG nurse after the insertion of the tube with no problems detected.

In summary, Mr Connor's peritonitis caused by his leaking PEG tube was a known complication of having the procedure. It does not appear that there were any systems issues regarding the medical and nursing care he received at the RHH.

Findings & Comments :

Having reviewed all of the available evidence I accept and adopt the opinions of Dr Lawrence and Ms Newman. Mr Connor's death is directly contributed by the surgical insertion of the PEG tube into his stomach and its subsequent leaking. I accept that this consequence is a known complication of this procedure and that there are no systems failures in any of the medical and nursing care provided to Mr Connor.

I conclude this matter by conveying my sincere condolences to Mr Connor's family.

DATED : 19 September 2011 at Hobart in Tasmania.


Glenn Hay