RECORD OF INVESTIGATION INTO DEATH (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Rod Chandler, Coroner, having investigated the death of
Frances Victoria Walker
WITHOUT HOLDING AN INQUEST
(1) Frances Victoria Walker (“Mrs Walker”) died on 18 July 2011 at the Launceston General Hospital (“the LGH”) in Launceston.
(2) Mrs Walker was born on 7 November 1911 and was aged 99 years. She was widowed and retired.
(3) Mrs Walker died from cardiac arrest with antecedent causes being acute on chronic renal failure and neck of femur fracture.
Circumstances of Death:
Mrs Walker was a long term resident of the Beaconsfield Multi-Purpose Centre at Beaconsfield. She was frail and her condition had deteriorated over the few months before her death. Although she was cognitively intact she was known to be impulsive at times. She had been assessed as a “high falls risk” and used a 4 wheeled walker.
At about 10.00 am on 17 July staff at the Centre were assisting Mrs Walker to have a shower. In the course of this event Mrs Walker had a fall, landing on the bathroom floor. Staff noted that her left leg appeared shortened and rotated and they suspected that she may have broken her left hip. The left hip area was very painful. Mrs Walker also complained of some shoulder pain. Centre staff were concerned that there was a risk of further injuring Mrs Walker if they moved her from the bathroom floor. To do so would also, in all likelihood, have caused her considerable pain. She was therefore made as comfortable as possible on the floor with a pillow placed under her head and a blanket laid over her for warmth. A call was then made to Ambulance Tasmania. (‘AT’) This was at 10.14am. Whilst waiting for the ambulance a staff member remained with Mrs Walker.
By 11.27am an ambulance had not arrived and a further call was made to AT. The dispatcher was advised that Mrs Walker was “getting quite distressed.” An ambulance had still not arrived by 1.52pm when a third call was made to AT. This time the dispatcher was advised that Mrs Walker was “lying on a concrete floor and is getting quite distressed.” The dispatcher advised that “we will be there as soon as we can.” At about 2.30 pm staff at the Centre made the decision to lift Mrs Walker on to her bed from the floor. They did this using a scoop stretcher which they had located in the ambulance bay. At 3.26pm the ambulance arrived and Mrs Walker was then conveyed to the LGH.
Mrs Helen Rosevear is a friend of Mrs Walker, having known her for over 30 years. She regularly visited her at the Centre. At about 10.15 am on 17 July she arrived at the Centre to see Mrs Walker. She was advised that she had had a fall. Mrs Rosevear went to her room and found Mrs Walker lying on the bathroom floor. Mrs Rosevear stayed with her for the next 4½ hours. She and staff from the Centre tried to keep Mrs Walker warm and comfortable with blankets, heat packs and pillows. At one stage staff contacted GP Assist and an order was obtained for Mrs Walker to be given subcutaneous morphine. This was administered three times during the wait for the ambulance.
A review of the records at the LGH reveal that Mrs Walker appeared to be comfortable on her arrival in the Emergency Department. She was administered morphine as analgesia and was then transferred to a Ward. At this time she was noted to be very drowsy. A “not for resuscitation” order was made by the Orthopaedic Registrar. During the evening of 17 July Mrs Walker was noted to have an elevated potassium level which was successfully treated. Her order for morphine as an analgesic was ceased in the early hours of 18 July with Fentanyl being ordered as a replacement.
The LGH’s medication chart shows that Mrs Walker received paracetamol at 5.10 am and 9.50 am on 18 July and Fentanyl was administered at 9.20 am and 12.00 noon only. It is noted that the order for Fentanyl was written up for Mrs Walker to receive every 15 mins. The records further show that in the Emergency Department she received 2.5 mg of morphine at 7.40 pm and this appears to be the only dosage of morphine administered apart from the 6 mg given by Ambulance Tasmania. These records do suggest that Mrs Walker was not given regular oral and/or parenteral analgesia.
Dr Ashley Crosswell was the anaesthetist assigned to the orthopaedic list for 18 July and he was advised that Mrs Walker may require a hip replacement in the late morning. He first reviewed her at about 11.30 am and noted that she was unwell, that she had not passed any urine since midnight, that she was incoherent in speech and unable to give any history. It was difficult for him to gauge her pain level because of her inability to communicate but stated; “she did appear to have moderate pain that was exacerbated by movement of her left leg.” Dr Crosswell noted that her clinical observations were unsatisfactory. She was hypertensive, had a mild tachypnoea, her respiratory rate was 20-30 pm and her oxygen saturations were greater than 92. In Dr Crosswell’s opinion Mrs Walker was gravely ill and was not a suitable candidate for surgery. He discussed her condition with her daughter Mrs Kaye McLean and assured her that he would endeavour to provide adequate analgesia to keep her mother comfortable. His plan was to keep her leg in skin traction, to continue regular paracetamol and also to continue Fentanyl with an increased dosage.
Subsequently Dr Crosswell discussed Mrs Walker’s situation with Anaesthetic Consultant, Dr Henning Els and a decision was then taken to administer a femoral nerve block. At about 1.00 pm that day they attended Mrs Walker to carry out this procedure but at this time her clinical condition had deteriorated further to the point where she was unresponsive even to painful stimuli. It was then decided that there was nothing to be gained by performing the nerve block.
Mrs Kaye McLean is Mrs Walker’s daughter. She visited her mother in the late afternoon of 17 July. She spoke to medical staff and was informed that Mrs Walker would require surgery but that it would not be carried out until the following morning. She was further advised that in the meantime she would be given a nerve block for pain relief. Mrs McLean learned the following afternoon that her mother had not received the nerve block either that previous evening or the next morning. No explanation has been provided for this not having occurred.
Mrs Walker died in the afternoon of 18 July 2011. A death certificate was issued by Dr T Mosetlhi. The cause of death is certified to be cardiac arrest with antecedent causes being acute on chronic renal failure and neck of femur fracture. The death was not reported to the coroner.
Findings, Comments and Recommendations:
The circumstances surrounding Mrs Walker’s death have been the subject of investigation. This has included a review of Mrs Walker’s records at the LGH and the obtaining of reports from LGH medical staff and from AT management. This material has been considered in detail at a meeting of the coroner, the coroner’s associate, a research nurse and forensic pathologist, Dr Donald Ritchey.
Because Mrs Walker’s death was not reported to the coroner there was not an opportunity for a forensic pathologist to conduct a post-mortem examination. Nevertheless, I am satisfied from the available evidence that Dr Mosetlhi has correctly described the cause of death in his certificate.
The circumstances surrounding Mrs Walker’s death give rise to two matters which require comment. The first concerns the response of AT. The second relates to Mrs Walker’s pain management at the LGH.
As the above history shows Mrs Walker had her fall at the Centre at about 10.00am on 17 July and the first call was made to AT at 10.14am. However, it was over five hours before an ambulance attended to take Mrs Walker to the LGH. For four of these five hours Mrs Walker lay on the bathroom floor. She required morphine to help her cope with her pain. This must have been an unpleasant and distressing ordeal, most particularly for Mrs Walker but also for those persons who were with her and providing comfort.
AT has provided a detailed report upon this incident. The principal explanation for the prolonged delay in attending to Mrs Walker is stated in these terms;
“I would like to highlight what I believe to be a most important point, which is that at no time during the day, from the time the case was booked, till the eventual transfer of Mrs Walker was there a clear opportunity for the transfer to occur that would not have resulted in a delayed response elsewhere in the Greater Launceston area. The primary issue was that the case load request on Ambulance Tasmania exceeded our available resources at the time. This is on occasion the nature of emergency services….”
I am assured that AT’s internal investigation of this incident has identified areas where improvements can be made in its service delivery and that a plan has been adopted for their implementation. It is hoped that these steps will eliminate, or at least markedly reduce, the likelihood of a similar event in the future.
As I have noted above the LGH records indicate that Mrs Walker did not receive regular oral and/or parenteral medication for pain relief. Too, although it seems that it was intended to administer a nerve block for pain relief on the night of Mrs Walker’s admission no steps were taken to provide this relief until the following afternoon by which time Mrs Walker’s deteriorated condition made the procedure unnecessary. These apparent shortcomings in the provision of pain relief do, in my opinion, warrant review by the LGH with a view to ensuring that pain relief is always delivered both promptly and regularly to its patients.
I am required, if possible to identify any person or entity who contributed to the cause of Mrs Walker’s death. Although AT’s response to attend Mrs Walker was unacceptably prolonged the evidence does not permit me to find that this delay caused or contributed to Mrs Walker’s death. Similarly, there is not any evidence that any shortcomings in the provision of pain relief by LGH was factor which contributed to the death. I therefore do not make any finding of contribution in this case.
There is a final matter which also requires comment. I have already noted that the LGH did not report Mrs Walker’s death to the coroner. Professor Bernie Einoder is the Director of Surgery at the LGH. He has explained the failure to report in these terms; “Since (Mrs Walker) did not have any surgical procedures I was unaware that it was our duty to report her death to the Coroner.” This statement demonstrates a real ignorance of the reporting requirements prescribed by the Coroners Act 1995. It leads me to recommend that the LGH undertake an education programme to ensure that its medical and nursing staff are familiar with the requirements of the Act, most particularly those provisions which identify the categories of deaths which are reportable and the obligations which attach to those deaths.
I convey my sincere condolences to Mrs Walker's Family.
Dated: 31 day of March, 2013.