A young mother who underwent routine surgery at Dubbo Hospital died of complications because doctors and nurses made mistakes.
Subscribe now for unlimited access.
$0/
(min cost $0)
or signup to continue reading
Coroner Hugh Dillon said hospital staff who cared for Kylie Greenaway were not morally deficient or grossly negligent “but they needed to place their faith in the diagnostic tool(s) they had in their hands rather than in their own fallible clinical assessments.”
Coroner Dillon handed down his findings in Sydney yesterday following an intensive investigation into Ms Greenaway’s death.
He found the 29-year-old died at St George public hospital in Sydney on August 25, 2010 due to complications following an iatrogenic injury to her bowel during elective surgery for an incisional hernia at Dubbo Hospital on August 19.
She suffered a perforation of the small intestine which led to abdominal infection and “a cascade” of further complications.
Coroner Dillon offered “sincere and respectful condolences” to Ms Greenaway’s parents, Steven and Noelene, and her son Hayden. The hospital offered an unreserved public apology to the Greenaway family.
“That is as it should be,” the Coroner said.
The inquest concluded Ms Greenaway was much loved and her family still grieved. Her parents spoke movingly and with great dignity about their warm and affectionate daughter, the closeness of the family and their tremendous sense of loss.
The inquest heard evidence clinicians and nurses who treated Ms Greenaway were greatly saddened and distressed by her death.
The family had accepted the hospital’s apology and significant reforms implemented as a result of Ms Greenaway’s death. But the pain of losing their daughter, mother and sister remained.
Mr Greenaway’s death had left a hole in their lives and it was difficult to come to terms with her absence.
“It is clear to me and, I am sure, to everyone else who attended the inquest that she will be deeply missed by those who knew her,” Coroner Dillon said.
The inquest was told Ms Greenaway’s laparoscopic hernia repair was performed by Dr Dean Fisher with the assistance of registrar Dr Nazanin Ahmadi.
The surgery was uneventful and Ms Greenaway was transferred to the Extended Day Surgery Unit (EDSU) for post-operative recovery.
In oral evidence Dr Fisher said in retrospect he thought placing Ms Greenaway in EDSU was inappropriate as he had never known a patient who had undergone the procedure to go home within 24 hours. Dr Fisher believed she was housed there due to bed shortages.
Nursing records show Ms Greenaway’s vital signs were within normal range throughout the remainder of August 19 and first part of August 20.
She was reviewed by doctors who thought her recovery was proceeding well and she should be kept in EDSU until pain symptoms were controlled with oral analgesia.
With the benefit of hindsight it was apparent Ms Greenaway’s condition had already begun to deteriorate.
The inquest heard not all Dubbo Hospital nursing staff had received training in “Between The Flags” - a colour coded program initiated by NSW Health in 2010 to record blood pressure readings and indicate when medical review or an emergency crash team was required.
The program was at roll-out stage and Ms Greenaway’s low blood pressure reading did not lead to clinical review.
Ms Greenaway was reviewed on August 21. The index of suspicion was not raised because the majority of her parameters were normal.
At 2pm on August 21 nurses attempted to take Ms Greenaway’s blood pressure. They were unable to obtain a reading and attempted to use another machine which also failed to record a reading. The nurses attempted to take her blood pressure manually which was again unsuccessful.
Despite the inability to take a reading and the fact Ms Greenaway had been vomiting during the day, staff were of view she was not critically ill. She was described as walking, talking and joking.
Resident Medical Officer (RMO) Dr Raymond Wu reviewed her condition at 5.30pm. He was unable to obtain a blood pressure reading and observed Ms Greenaway was in pain.
After the nursing hand-over around 9.30pm, staff could still not obtain a blood pressure reading. Ms Greenaway continued to ambulate and appeared well with the exception of occasional vomiting.
Between 2am and 3.30am her condition was raised with night RMO Dr Ken Looi. Due to commitments in other parts of hospital he was unable to see Ms Greenaway until around 5am on August 22.
He recorded Ms Greenaway was “feeling like crap” - she was moaning, groaning, retching and her blood pressure remained unrecordable.
Dr Looi initiated an arrest call which resulted in transfer to the Intensive Care Ward (ICU). By late morning, consultant Dr Michael Sinclair formed the impression Ms Greenaway was suffering from severe sepsis.
She was returned to the operating theatre where a laparotomy was performed by Dr Fisher. He found Ms Greenaway was suffering from a small bowel perforation connected with the first surgery which in turn resulted in the development of necrotising fasciitis in her abdomen.
After her return to ICU Dr Randall Greenberg recorded Ms Greenaway could open her eyes and obey commands but was nonetheless critically ill.
The management plan focused on maintaining blood pressure in an attempt to reverse acute renal failure associated with sepsis.
At 11.20am on August 23 Ms Greenaway was taken into surgery for a further laparotomy.
After leaving theatre she was transferred to Sydney by air and road, arriving at St George Hospital around 7.30am on August 23.
Another laparotomy was performed under Dr Daniel Kozman. Ms Greenaway remained minimally responsive. Her neurological status was a severe concern.
After a scan conducted on afternoon of August 24 medical staff concluded Ms Greenaway was suffering an irreversible loss of brain function.
A conference was held with the family. Ms Greenaway was disconnected from life support and declared dead at 8.22am on August 25.
The inquest heard Ms Greenaway had not displayed the usual symptoms of someone with very low blood pressure, such as dizziness and difficulty in standing and walking.
This seemed to have misled nursing staff into thinking a blood pressure problem “was with the machines they were using, not with Ms Greenaway”.
Coroner Dillon found assumptions should have been challenged.
He said it would have been easy to test the machines - nurses could have tested each other’s blood pressure or taken a reading from another patient.
The Coroner found nursing staff did not recognise the gravity of some of Ms Greenaway’s symptoms and tried to find a solution to the problem they perceived or assumed rather than the actual predicament the observation chart was indicting.
The inquest heard most of the nurses caring for Ms Greenaway were experienced people but opportunities to recognise she needed surgical intervention for peritonitis were lost.
The Coroner found the fact Ms Greenaway was on EDSU may have contributed. It was separate from general wards and at night staffed by only one enrolled nurse and a junior doctor who (at that time) was engaged elsewhere in hospital.
The inquest heard deterioration may have been picked up earlier on another ward with more experienced staff.
Immediate action was taken once Ms Greenaway was recognised as a very sick patient. Unfortunately it came too late, Coroner Dillon said.
Consultant surgeon Professor David Morris and nursing expert Professor Meena Davies were highly critical of the care given to Ms Greenaway at Dubbo Hospital and the delay in transferring her to Sydney.
The death had caused Dubbo Hospital administrators and senior medical and nursing staff to re-evaluate practices and structures.
All staff had been trained in the “Between The Flags” program and the EDSU had been integrated into the surgical ward.
Nursing and medical management procedures had been put in reduce the risk of (patient) deterioration going undetected for long.
The hospital had altered its surgical booking procedure to enable better planning of post-operative care for surgical patients.