Clinical failures, delays contributed to woman’s death after pain ordeal, Tasmanian coroner finds
A Tasmanian coroner has raised concerns about patient transfers between the state’s hospitals, after the death of a 53-year-old woman.
Trudi Maree Forward died at the Royal Hobart Hospital (RHH) on 27 August 2014, from sepsis and multiple organ failure.
A week earlier she had undergone urgent vascular surgery after being transferred from the Launceston General Hospital (LGH).
Coroner Rod Chandler found there were delays at the LGH in diagnosing Mrs Forward’s condition, a blocked mesenteric artery which restricted blood flow to her intestines.
The condition is a medical emergency, with a mortality rate of 60 to 80 per cent.
The coroner said survival was enhanced if the condition was quickly diagnosed and treated, ideally within six hours — but in Mrs Forward’s case it took 36 hours.
In his findings, Mr Chandler said the records of Ambulance Tasmania showed “at 6:27am on Tuesday 19 August 2014 paramedics attended at Mrs Forward’s home”.
She had complained of “severe abdominal pain along with nausea and vomiting” and other symptoms coming on around 3:00am, he said.
Mrs Forward was taken by ambulance to the LGH, arriving at the emergency department at 7:09am.
She was seen by a number of clinicians, during which time, Mr Chandler noted, she had complained to LGH staff “my tummy is going to explode”.
The coroner said five hours and 33 minutes elapsed between RHH agreeing to the transfer and Mrs Forward’s arrival at 2:18pm, with a further five hours elapsing before she was seen by a surgeon.
Mr Chandler said the delay was due to a number of factors including an “apparent lack of urgency” in transporting Mrs Forward the 198 kilometres to RHH, an “apparent lack of urgency” in carrying out the surgery and a decision not to operate at the LGH.
He said the case also “illustrated a patient transfer system functioning below par” with concerns over the time taken to call an ambulance then prepare the patient for transfer.
Mr Chandler found the “general tone” of evidence from several specialists at the LGH was that “lengthy transfer times were a relatively common and frustrating experience”.
He found the delay was caused by:
- The “failure by LGH clinicians to identify mesenteric ischaemia as a differential diagnosis in the early stages of Mrs Forward’s presentation”
- The “failure to identify an occluded superior mesenteric artery from the CT scan”
- The “unwillingness on the part of vascular surgeon David Stary to involve himself in Mrs Forward’s care and to perform a thrombectomy at the LGH”
- An “apparent lack of urgency in transporting Mrs Forward to the RHH, such that over five-and-a-half hours elapsed from the time her transfer was accepted and her arrival at the RHH”
- An “apparent lack of urgency at the RHH in carrying out Mrs Forward’s thrombectomy”
Mr Chandler said a post-mortem identified a further thrombus in the superior mesenteric artery and “in light of these matters it cannot be said that Mrs Forward would have survived”.
Among his recommendations, Mr Chandler said the Tasmanian Health Service (THS) should review the circumstances of Mrs Forward’s transfer, “which may identify shortcomings in the system and facilitate improvements”.