Record of Investigation Into Death

Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

These findings have been de-identified by direction of the Coroner pursuant to S.57(1)(c) of Coroners Act 1995.

I, Stephen Raymond Carey, Coroner, having investigated the death of

"Mr. M."


Find That :

(a) The deceased died on 23 July 2011 at the Royal Hobart Hospital.

(b) "Mr M" was a married person aged 70 at the date of his death, having been born in 1941.

(c) "Mr M" was a retired person.

(d) "Mr M" died as a result of bleeding from the common bile duct and pancreatitis following endoscopic retrograde choledocho-pancreatography for metastatic carcinoma in the liver (surgically corrected). He also had enlargement of the heart.

Circumstances Surrounding the Death :

"Mr M" resented at the Royal Hobart Hospital, Emergency Department, with his on 14 July 2011 with reddish colour urine and abdominal pain. During his time in the Emergency Department "Mr M" underwent a CT scan, x-ray and blood and urine tests. He was admitted to a Ward of the hospital during the morning of 15 July 2011. His urine returned to colour yellow by later that day and his pain had also resolved. He was discharged home late in the day on 15 July 2011 with a plan for him to have another CT scan the next week and a follow up appointment was made with his oncologist (Dr Young) for four days time. His wife reports that they were both frustrated that no conclusion had been drawn about "Mr M's" state of health during this hospital stay. "Mrs M" reports that during the following days 16, 17 and 18 July although her husband's attitude remained positive, he repeatedly mentioned discomfort on the right side of his body and she became concerned about this as it was not his habit to complain about pain. Towards the end of this period they both noticed a slight change in his pallor, suggestive of jaundice. On Tuesday 19 July "Mr M" was seen by Dr Young, the oncology specialist at the out-patient clinic at the Royal Hobart Hospital. Dr Young notes that "Mr M's" liver metastases were slightly increased in size (as per his repeat CT scan), however his main complaint was very itchy skin. Dr Young notes after this consultation that;

"Discussed with Mr R Bohmer - needs ERCP. Associate Professor Wilkinson's Registrar to liaise with patient directly…….".

In the medical record a letter Dr Young wrote to Mr M's general practitioner states;

"I discussed "Mr M's" situation with Rob Bohmer after "Mr M" had left the clinic today and he agrees that "Mr M" should have a ERCP. Rob had Steve Wilkinson's Registrar in the room with him and apparently Steve is the one performing ERCP at Royal at present, otherwise "Mr M" would need to perhaps be sent into the private sector (funded by the Royal Hobart Hospital) to have the ERCP performed as manpower within Gastroenterology in Royal isn't sufficient."

Accordingly "Mr M" was admitted to the Royal Hobart Hospital on 20 July 2011 and had the ERCP (endoscopic retrograde cholangiopancreatogram) performed on the same day by Mr Wilkinson. Apparently the aim of this surgery was to insert a stent in the common bile duct, however due to problems encountered the surgery was unsuccessful. During the ERCP a hepatic level obstruction was encountered together with possible stricture and a nasobilary tube was inserted to aid drainage, however post the ERCP there was no significant drainage from the tube.

"Mr M" was returned to the Ward post this procedure and routine blood tests conducted that evening demonstrated pancreatitis, he was noted however as being stable and comfortable. Intravenous fluids were increased and Mr M's intake was restricted to clear fluids. On 21 July 2011 "Mr M" underwent a fluoroscopic investigation via the nasobilary tube he had insitue. This is reported as showing;

"……………no filling biliary system. Contrast ->  portal vein. No complication."

The repeat cholangiogram did not identify any of the duct system, this result was reviewed by the surgical team who concluded that there was no point in stenting due to the cancer. That evening "Mr M" vomited "coffee ground" vomitus. He was reviewed by an intern who queried whether he had an upper gastrointestinal tract bleed, however as "Mr M" was stable and his pain had settled post vomiting he was merely kept under observation.

On 22 July 2011 initially "Mr M" was noted to be in good spirits when his wife arrived at approximately 9.00 am. However an emergency call was placed for "Mr M" who collapsed when being assisted to stand by a nurse to obtain a standing blood pressure reading. The Intensive Care Unit Registrar who attended noted that "Mr M" was likely suffering from bleeding from his upper gastrointestinal tract or his retropetroperitoneum. "Mr M's "haemoglobin level had been decreasing over the previous 24 hours. He was transfused with two units of packed red blood cells and active treatment continued. "Mr M" remained on the Ward and was reviewed by the gastroenterology team during the afternoon. They noted that his clinical situation was grave and record that this was discussed with "Mr and Mrs M" who appeared to understand. Given advice provided subsequently by "Mrs M", this may not have been an accurate reflection of their understanding. "Mrs M" can recall having discussions with a young doctor and by this stage she had noted a marked deterioration in her husband's physical condition. She recalls the discussion centring around the issue of "how much should be done for K?". She described how she was extremely stressed at the time and feels that she was not in a proper state of mind to seek or understand the information that she wanted to receive at that time. "Mrs M" does not believe she gave any clear agreement about discontinuing further treatment for her husband, however in retrospect she accepts that this may have been inferred because she did make a comment about not wanting her husband to suffer.

"Mr M" was the subject of another emergency call that evening when his conscious state decreased. Clinical examination revealed that he had a distended and painful abdomen and his respiratory and heart rates were increased. The Surgical Registrar discussed his situation with Mr Bohmer and Mr Wilkinson. Both these Consultants agreed that "Mr M" should not undergo further invasive investigations, especially as he was not a surgical candidate. His resuscitation status was again discussed and he was deemed "not for resuscitation". However in the short term he continued to receive antibiotics, fluids and pain relief.

"Mr M's" condition continued to worsen and his pain increased. He deteriorated markedly in the early hours of 23 July 2011 and died at 2.30 am.

It is apparent that having been admitted for investigation of pain, gastrointestinal bleeding and jaundice, a decision was made after the jaundice became more pronounced to attempt to insert a stent in the common bile duct in order to relieve this jaundice. "Mr M" developed pancreatitis and gastrointestinal bleeding following this procedure and ultimately died.

Autopsy confirms the surgical findings of a dilated stricture, haemorrhage in the bile duct and also acute pancreatitis in the surrounding pancreas. Both pancreatitis and bleeding are recognised complications of ERCP (endoscopic retrograde choledocho-pancreatography). The autopsy findings also included advanced metastatic colorectal cancer and there was still residual metastatic cancer in the liver despite extensive previous surgery on the liver. Accordingly it was felt that the long term prognosis for "Mr M" at the time he underwent this treatment was very poor.

Comments and Recommendations : 

The circumstances surrounding the death of "Mr M" and in particular his final treatment at Royal Hobart Hospital has been the subject of a detailed clinical analysis. Given "Mr M's" overall poor prognosis given the cancer that had affected various parts of his body, the advisability of undergoing the ERCP procedure has been considered. Up until that time "Mr M" was apparently maintaining a positive lifestyle, being in good spirits and able to walk together with his wife and also work around the house and in his garden. The procedure would, if successful, have relieved the jaundice and perhaps assisted in prolonging his life. However the procedure does have associated risks. I note that the decision to undertake this procedure was taken after discussion between two specialists, Mr Bohmer and Mr Wilkinson, who were well aware of his previous medical history as well as the relatively high complication rate for the procedure. I do not consider that there is any basis to be critical of the exercise of clinical judgement by the doctors involved in this treatment of "Mr M".

Communication difficulties appear to have occurred initially when according to "Mrs M" neither she nor "Mr M" fully appreciated the poor medical state he was in upon presentation to hospital and his poor prognosis after this surgical procedure. It is apparent from material provided by "Mrs M" that she does not accept that she was aware of the serious nature of the surgery to be undertaken on her husband and in particular the high possibility of the complications that did in fact occur. She also expresses concern in relation to a number of communication issues between herself and staff at the Royal Hobart Hospital, in particular the medical staff. The loss of a loved one within a hospital environment following a medical procedure will always be an emotional and stressful time and despite the pressures upon their time, medical staff must be mindful of this human factor and the need to clearly communicate to patients and their family what is occurring.

Before concluding I wish to convey my sincere condolences to the family of "Mr M".

Dated: This 12 day of December 2011 at Hobart in the State of Tasmania


Stephen Raymond Carey