Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Rod Chandler, Coroner, having investigated the death of
Raymond Frederick Waite
WITHOUT HOLDING AN INQUEST
Find :
(a) Raymond Frederick Waite ("Mr Waite") died on 30 March 20008 at the Royal Hobart Hospital (the Royal") in Hobart, aged 87 years;
(b) Mr Waite was born in Queenstown on 24 December 1920. He was married in 1942 and had one adult daughter;
(c) Mr Waite died as a result of complications of paraplegia resulting from a displaced fracture of the thoracic vertebral column sustained in a fall from standing height.
Background:
Mr Waite lived at home at Rosetta with his wife, Merle, prior to admission to the Royal on 21 March 2008. They had one adult daughter. Mr Waite’s wife has a dementing illness and his daughter has a cognitive impairment following a brain tumour. Mr Waite’s granddaughter, Ms Jo Waite ("Ms Waite") assisted with their affairs.
Mr Waite had been referred to the Hobart District Nursing Service in March 2000 and initially received two hygiene assistance visits per week. Over time his need for assistance and care was increased so that by March 2008 he was receiving twice daily visits from the Service. Periodically, placement in a nursing home and/or respite care were discussed with Mr and Mrs Waite but both refused. A number of falls by Mr Waite were documented by District Nurses over 2007 and 2008. In November 2007 he was admitted to Calvary Hospital for investigation of his leg weakness. It appears Mr Waite was discharged with a letter for his general practitioner indicating he was now mobile with a walking frame and that his mobility was limited by his weight. Mr Waite had a history of long standing inner ear disease.
Circumstances:
Mr Waite initially presented to the Department of Emergency Medicine (DEM) at the Royal on 17 March 2008 complaining of back and abdominal pain from a fall about 6 days previously. Lumbar spine x-rays did not disclose a fracture.
Mr Waite again presented to DEM by ambulance on 21 March 2008. He had had further falls at home and was unable to get up from the floor. Mr Waite was admitted to the Royal, and was under the initial care of Dr Richard Yu.
Nursing notes made on admission indicate that Mr Waite was demanding, frequently pulling off his urosheath, removing his intravenous drip, and tipping drinks into his bed. He was not always oriented to place. Chest and abdominal x rays were carried out but the report states that the film was of such poor quality that they were of "limited diagnostic utility."
On 23 March 2008 Mr Waite was complaining of weakness and was found to be hypo-reflexive in his lower limbs. Blood tests indicated deranged levels of his urea and electrolytes and the medical notes queried whether Mr Waite’s problems included a ‘renal component.’
On 24 March 2008 Mr Waite remained in bed all day. He stated to nursing staff that his legs didn’t work. He was reviewed by a medical intern. Notes indicate there was peri-umbilical tenderness but no note was made regarding leg function.
On 25 March 2008 Mr Waite was found to have worsening renal function and was still hypo-reflexive in his lower limbs. It was noted in his medical record; "consider imaging subsacral spine if ongoing weakness." Nursing notes indicate that Mr Waite required assistance from orderlies to move in bed.
On 26 March 2008 Mr Waite’s urea level was still high. Medical notes state; "need to exclude upper gastrointestinal tract bleed." On this day Mr Waite was seen by physiotherapist, Ms Lauren Chapman. She observed that he was unable to move his lower limbs and that he required maximal assistance to roll side-to-side. She also noted that Mr Waite was incontinent of faeces. She paged a medical intern to advise of these matters including her findings of loss of sensation and strength in the lower limbs.
Mr Waite continued to complain to nursing staff of abdominal pain and that his legs would not move. He was seen by medical intern, Dr Alan Lee. It seems that his examination focussed on the cause of Mr Waite’s abdominal pain. The notes do not indicate whether Dr Lee spoke with his medical registrar on that day nor is there any record of any neurological findings related to Mr Waite’s legs.
On 27 March 2008 Mr Waite was still complaining of abdominal pain which increased on movement. When examined he was unable to move his lower limbs, and was found to have no sensation below T10. Mr Waite was then sent directly for a CT scan of his spine. It was reported that Mr Waite had a ‘fused spine ++++’, with a fracture detected at T9/10 and extending through the disc space with displacement of fragments. That same day Mr Waite was seen by the neurosurgery registrar who noted; ‘complete paralysis from T10.’
On 28 March 2008 the medical unit reviewed Mr Waite’s case and the medical consultant (Dr Nicklason) spoke with Mr and Mrs Waite, along with Jo Waite. He explained that Mr Waite had a fractured spine which was considered to be inoperable and that he was paralysed. They were informed that Mr Waite would require long term nursing home care. On the same day Mr Waite was separately examined by the neuro surgery team and the surgical team.
On 29 March 2008 Mr Waite was seen by a medical unit intern as it had been noted on a blood test that he had a raised level of potassium. Mr Waite was administered resonium for this. Later that day the medical intern again reviewed Mr Waite and queried whether he had pneumonia.
During the early hours of 30 March 2008 a MET call was made after it was noted that Mr Waite’s oxygen levels were dropping and he was in significant pain. Ms Waite was contacted and Mr Waite’s prognosis discussed. It was agreed that comfort care only would be provided.
Mr Waite died at 9:15 am on 30 March 2008.
A post-mortem examination was undertaken by forensic pathologist, Dr Donald Ritchey. In his opinion the cause of Mr Waite’s death was "complications of paraplegia resulting from a displaced fracture of the thoracic vertebral column sustained in a fall from standing height. A significant contributing factor was severe osteopenia."
In the course of investigating this matter multiple attempts were made to obtain a statement from Dr Alan Lee. However, all have been unsuccessful. It appears that Dr Lee may no longer be in Australia. In the result the investigation has not had the benefit of Dr Lee’s account of his care of Mr Waite. In particular an explanation has not been obtained from Dr Lee for his apparent emphasis on Mr Waite’s abdominal difficulties to the exclusion of his loss of function of his lower limbs at the time of his attending Mr Waite on 26 March.
The investigation of this death has been assisted by a report provided by Dr Frank Nicklason, a staff specialist physician at the Royal. Dr Nicklason’s report includes these comments:
"1. It seems possible that the fracture of the spondylitic spine occurred 6 days prior to the patients initial presentation to the emergency department. An xray done during this presentation was of the lumbrosacral spine and did not reveal the fracture at a higher level (T9/T10)…."
2. It seems likely that the dislocation of the fracture fragments occurred later perhaps in hospital as the patients neurological status declined in hospital.
3. It seems that the patients abdominal pain was referred pain as a result of spinal cord compresion
4. It seems that many factors made caring for this man with complex needs difficult
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He had multiple medical problems
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He was admitted over the Easter period
5. The first record of neurological assessment revealing unequivocal signs in the legs were noted by the physiotherapist on 26/03/08
6. It is not clear that Medical Intern Alan Lee who was (apparently) contacted by the physiotherapist appropriately assessed the patient and communicated with more senior doctors.
7. Medical Intern Alan Lee overturn a not for resuscitation order without discussion with a more senior doctor. This could have compromised the delivery of palliative care to the patient.
8. The patient developed a sacral pressure sore as a result of his immobility as well as a terminal hypostatic pneumonia.
9. It seems likely that Mr Waites admission over the Easter period contributed to late recognition of his neurological condition (but this is not tendered as an excuse). Suboptimal communication seems also to have been a factor."
Dr Jane Tolman is the Royal’s Director of Geriatric Medicine. She has provided a lengthy written account detailing Mr Waite’s care and commenting upon it. It’s helpful for me to set out the following portion of that document:
"Conclusions about this case:
1. On his previous admission a year earlier, it was obvious that Mr Waite did not have normal cognition.
2. His presenting problem was that of lower limb weakness. Mr Waite describes being unable to get off the floor after his legs gave way. The issues noted by the admitting doctor failed to address either his bowel or motor problems.
3. Symptoms of bowel obstruction predated the admission. The ED nurse reported his having abdominal pain, nausea and distension. The admitting doctor noted a lack of constipation or diarrhoea.
4. He was a very sick man with multiple problems and a poor prognosis.
5. There seems to have been no mention of sensation being discussed prior to the physiotherapist on 26.03.2008. It is not clear from the notes if the patient was asked about this.
6. It is not clear from the notes that an adequate physical examination was done at entry. "Moving all limbs" is insufficient for a man who describes his legs giving way, and then being unable to get off the floor.
Issues:
1. The quality of the histories was poor. The nurses and physiotherapist obtained a much better history than the doctors. While he was cognitively not normal, I gained the sense that the doctors failed to listen to his concerns.
2. The quality of the examination was questionable.
3. His outlook from the first was bleak. When the consultant was informed of his cord compression, he acted appropriately in arranging a family meeting with the grand-daughter and commencing pain relief.
4. The medical team, though, failed to address the issue of limitation of treatment orders at any time. This should not have awaited the patient’s decision. This should have been a medical decision based on his age (and potential for recuperation), his cognition, his cord compression, his bowel obstruction, his cardiac condition and so on. The resonium and AFO[ankle foot orthosis – a device to alleviate pressure areas on heels] would not have contributed to the quality of his life.
5. Resonium was probably not indicated for a potassium of 6.1 mmol and it should certainly not have been written as a standing order of four times a day.
6. There are several occasions in which the nursing notes refer to a medical order (eg having him placed NBM or the passage of a flatus tube or NGT). But these have not been documented by the doctor concerned.
7. Three teams were involved in his management. But there seems to have been little collaboration. A holistic approach to his care was lacking.
8. There are two documented occasions on which his grand-daughter was contacted. But it is unlikely that the family had a good understanding of his situation and prognosis.
Suggestions:
1. Geriatric patients (multi-system older patients and especially those with failing cognition), should have allied health multi-disciplinary team input from the first. Social work input, particularly, would have been useful.
2. There should be a family meeting early on and families should be kept informed of progress.
3. Medical teams should be able to take a good history and do an appropriate examination. This will include understanding when particular parts of the examination are required. (A case of pneumonia, for example, will usually not require a full neurological examination. A case of collapse with lost power clearly will always require it).
4. Appropriate medical management of older people must incorporate an assessment of all the needs of the patient and his family. It should not be based on a single organ or system.
5. A comprehensive plan should be devised early in the admission of the elderly. This needs to address, particularly, the limitation to treatment. This includes but is not limited to the NFR order. For example, in this case, it was clear he was going to do badly, and yet he was given resonium (which is difficult to take) and an AFO (with frequent changes which must have been uncomfortable), symptomatic treatment was not really addressed until a few hours before his death.
6. Medical leadership means making decisions about end of life orders. These should not be given to the patients when it is clear that treatment would be futile. Particular sensitivity needs to be exhibited when these issues arise in patients with limited cognitive function."
Findings, Comments and Recommendations:
I am satisfied that a thorough and detailed investigation has occurred into the death of Mr Waite and that there are no suspicious circumstances.
I accept the opinion of Dr Ritchey and find that Mr Waite died as a result of complications of paraplegia resulting from a displaced fracture of the thoracic vertebral column sustained in a fall from standing height.
It is apparent, in my view, that the standard of care afforded to Mr Waite following his admission to the Royal on 21 March 2008 was deficient in many respects. Those deficiences have been clearly identified by Dr Nicklason and Dr Tolman in their respective reports and it is unnecessary for me to repeat them.
When he was admitted on 21 March Mr Waite was very unwell and his prognosis was poor. In my view, Mr Waite’s death was unlikely to have been avoided even if he had received optimal care. Nevertheless, it is my further view that if Mr Waite had received proper and appropriate treatment his last days could have been made more comfortable for him and less stressful, not only him, but also for his family members.
It is my recommendation that all events surrounding the management of Mr Waite be reviewed by the Royal with the aim of remedying those deficiencies in his care which have been identified. In particular, it is my recommendation that the Royal give serious consideration to the implementation of that multi-discipline approach advised by Dr Tolman for the treatment and care of elderly patients who present with complex histories including impaired cognition.
I conclude this matter by conveying my sincere condolences to Mr Waite’s family.
DATED : 16 May 2011 at Hobart in Tasmania.