Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Rod Chandler, Coroner, having investigated the death of
Patricia Edna Glover
WITHOUT HOLDING AN INQUEST
Find
a) Patricia Edna Glover (‘Ms Glover’) died on 27 June 2012 at the Lenah Valley campus of Calvary Health Care Tasmania Limited, (‘Calvary’) at 49 Augusta Road in Lenah Valley.
b) Ms Glover was born on 14 September 1940 and was aged 71 years.
c) Ms Glover was unmarried and resided at 5/12 Tilyard Street in Montrose.
d) Ms Glover died from sepsis due to peritonitis complicating a small bowel perforation that occurred following multiple abdominal surgeries. Significant contributing factors were a previous cholecystectomy, obesity with laparoscopic band placement and diverticular disease.
e) No person contributed to the cause of Ms Glover’s death.
Circumstances
1. Generally Ms Glover was active and enjoyed good health. In 2004 she had laparoscopic banding surgery carried out by a Mr Patiniotis. Thereafter Ms Glover lost weight and remained at her target weight. In November 2010 she had a colonoscopy, also performed by Mr Patiniotis. This procedure showed severe sigmoid diverticulitis of the colon. Ms Glover was advised that she would need surgery for this condition at some time in the future.
2. In 2012 Mr Patiniotis referred Ms Glover to colorectal laparoscopic and general surgeon, Mr Srini Yellapu. He obtained a background history of severe diverticular disease and chronic constipation on-going for several years.
3. On 8 May 2012 Mr Yellapu operated on Ms Glover at the Hobart Private Hospital. (‘the Private’) The procedure involved the cutting out of a section of diseased bowel and forming an ileostomy for the purpose of passing excrement. The hospital records show a slow but steady improvement despite episodes of pain and nausea. Ms Glover was discharged home on 28 May 2012. Thereafter Ms Glover attended her general practitioner on two occasions with complaints of nausea, an inability to eat and pain. She was treated with analgesia.
4. On 4 June 2012 Ms Glover attended the Stomal Therapy Unit at the Royal Hobart Hospital for follow-up. She was found to be dehydrated, suffering from nausea and vomiting and unable to tolerate diet or fluids. She was referred to Calvary to be seen by Mr Carey Gall as Mr Yellapu was on leave. Ms Glover was assessed in the Emergency Department and then admitted to a ward.
5. At 4.15pm on 4 June Ms Glover was reviewed by Mr Gall. She was diagnosed with a partial small bowel obstruction. Standard care was initiated and a CT scan of the abdomen ordered. The CT scan performed the following day showed evidence suggestive of a small bowel obstruction at the level of the stoma site. A stomal therapist undertook a stomal washout which only had a minimal result.
6. By 9 June Ms Glover’s clinical condition had deteriorated. A further CT scan confirmed a persistent small bowel obstruction. Mr Gall recommended further surgery. The following day he carried out a laparotomy and found an obstructed internal hernia with volvulus (twisting of the bowel). The condition was repaired and Ms Glover was transferred to the Critical Care Unit for post-operative management. By 13 June she had recovered sufficiently to be transferred to a general ward.
7. Over the following days Ms Glover steadily progressed eating a light diet, mobilizing and being pain free. She did however have ongoing high output from her stoma and was not able to cease her intravenous fluids due to being dehydrated. Her oral intake was fairly minimal.
8. By 23 June Mr Yellapu had returned from leave. On that day Ms Glover’s situation was discussed by Drs. Yellapu and Gall and they agreed that closure of the loop ileostomy (reconnection of the bowel) was the best therapeutic approach. On 25 June Mr Gall performed this surgery at Calvary. Mr Gall reported the operation was difficult due to adhesions and a chronically dilated and thin bowel. Ms Glover was returned to the ward at 10.00pm. Her pain score was 8-9/10 with a heart rate of 105 beats per minute.
9. Overnight Ms Glover suffered ongoing and severe pain in her abdomen. She was tachycardic and had an exquisitely tender abdomen. At 4.15am on 26 June she was reviewed by the House Medical Officer. He noted her to be distressed. He further noted her pain, tachycardia and oliguria (minimal urinary output). Her heart rate was 120 bpm. The HMO discussed Ms Glover with Mr Gall who ordered analgesia, fluids, paracetamol and an urgent CT scan of the abdomen. It was undertaken at 7.00am and showed evidence of peritonitis. At 8.50am Mr Gall reviewed Ms Glover and a decision was taken to carry out an emergency laparotomy.
10. The laparotomy was commenced at 1.30pm on 26 June. Mr Gall was assisted by Mr Yellapu. Their findings included a small bowel leak with gross peritonitis. Ms Glover’s old gastric band was removed and the jejunum (the mid-section of the small intestine) was bought to the surface of the abdomen via a stoma, a section of small bowel was removed and the bowel either side of the removed portion was re-joined. Ms Glover was then transferred to ICU and standard therapy was initiated by the ICU nursing staff. Ms Glover was critically unwell and required increasing amounts of inotropic medication to support her cardiovascular system and other vital bodily functioning. Overnight Ms Glover deteriorated further. She died at 9.30am on 27 June 2012.
Investigations
11. A post-mortem examination was carried out by Forensic Pathologist, Dr Donald Ritchey. In his opinion Ms Glover died as a result of sepsis due to peritonitis complicating a small bowel perforation that occurred after multiple laparotomies. Significant factors contributing were a previous cholecystectomy, obesity with laparoscopic band placement and diverticular disease.
12. Separate from the post-mortem examination the investigation of this death has included:
(i) The provision of an affidavit by Mr John Edwin Glover, the brother of Ms Glover;
(ii) Obtaining reports from Mr Yellapu and from Mr Gall;
(iii) Obtaining reports from Calvary;
(iv) An examination of Ms Glover’s medical records from the Private and Calvary undertaken by Research Nurse, Ms Libby Newman and
(v) The consideration of advice provided by Clinical Professor A J Bell, as medical advisor to the Coroner.
Discussion
13. I have set out above Dr Ritchey’s opinion upon the cause of Ms Glover’s death. I accept this opinion.
14. I have considered the circumstances surrounding Ms Glover’s surgery undertaken by Mr Yellapu at the Private and the post-operative treatment leading to her discharge three weeks later. I am satisfied that the standard of care provided to Ms Glover at the Private was of good quality.
15. It is apparent that Ms Glover’s condition as presenting on 4 June 2012 required her re-admission to hospital. I am satisfied that the initial treatment received by her at Calvary, including the bowel obstruction surgery carried out by Mr Gall, was in accord with standard practice and no criticism is made of it.
16. It is also apparent that following the surgical relief of her bowel obstruction Ms Glover’s losses via her ileostomy were excessively high and required continual intravenous fluids and specially formulated nutritional fluid. It was appropriate by the time Mr Yellapu returned from leave on 23 June for the surgical closure of the ileostomy to be undertaken. This occurred on 25 June and again was carried out in a proper manner. However, regrettably it led to a tear of the small bowel which I accept to be a known complication of this procedure.
17. The evidence shows that at the time Ms Glover was examined by Calvary’s House Medical Officer in the early hours of 26 June that she was suffering peritonitis due to a bowel leak or bowel infarction. This was confirmed by CT scan taken at 7.00am that day. It is common knowledge that peritonitis is a critical illness and in Ms Glover’s circumstance required an emergency laparotomy if she was to survive. Unfortunately this surgery was not commenced until 1.30pm on 26 June, that is some 6.5 hours after it should have been apparent that it was required. The reason for this delay has been the subject of particular enquiry.
18. Ms Kathryn Berry is the CEO of Calvary. She explains the delay in taking Ms Glover to theatre in these terms;
“The request from the surgeon for theatre time was indicated as being requested ‘around lunch time’ and at no time did the surgeon request an earlier start time for this case. Options to delay or cancel other cases were provided however this offer was not taken up by the surgeon and an afternoon list start was delayed to enable the case to proceed.”
19. Mr Gall initiated the arrangements for the emergency laparotomy. He says that at about 9.00am on 26 June he communicated with Sister Maxine Watson, Calvary’s Theatre Nurse Co-Ordinator, and advised her that Mrs Glover required surgery “that morning and could not wait.” He expressly rejects the contention that he requested a theatre ‘around lunchtime’ and says that he made it clear that he would be in his rooms that morning and would be available to perform the surgery as soon as a theatre became available. He accepts that because of necessary preparatory steps Mrs Glover may not have been ready for surgery until about 11.00 to 11.30am. However, he cannot explain why it was not until 1.30pm that the surgery began.
20. It is apparent that for whatever reason there was a communication breakdown between Mr Gall and Calvary’s theatre co-ordinating staff so that the surgery proceeded at least two hours later than it should have done thus denying Ms Glover the optimal chance of survival. However, the evidence does not permit me to make a positive finding that the outcome for Ms Glover would have been different if the delay in surgery had been avoided. Nevertheless, this case does serve as an opportunity to recommend to Calvary that it review its procedures to ensure that all critically ill patients requiring emergency surgery are treated without delay.
21. In the course of investigating this matter Calvary provided a copy of its emergency team calling and response protocols. I am advised by Clinical Professor Bell that these protocols do not employ the multi-observational scoring systems which have been proven to be better at detecting the deteriorating patient and are recommended by the Australian Commission on Safety and Quality in Health Care. In light of this advice it is my further recommendation that Calvary review its protocols on this subject and give consideration to adopting a multi-observational scoring system.
Comments and Recommendations
22. I have decided not to hold a public inquest into this death because my investigations have sufficiently disclosed Ms Glover’s identity, the time, place, relevant circumstances concerning how her death occurred, and the particulars needed to register her death under the Births, Deaths and Marriages Registration act 1999. I do not consider that the holding of a public inquest would elicit any important information further to that disclosed by the investigation conducted by me. The circumstances of Ms Glover’s death do not require me to make any further recommendations or comment.
I conclude by extending my sincere condolences to Ms Glover’s family and loved ones.
Dated the 18 day of October 2013 at Hobart in the State of Tasmania.
Rod Chandler
CORONER