Death of Berkeley man avoidable, inquest told

By Veronica Apap
Updated November 5 2012 - 6:24pm, first published October 29 2008 - 11:08am

The death of a Berkeley man at Wollongong Hospital could have been prevented had his deterioration after surgery been better recognised by senior medical staff, a coronial inquest heard yesterday.During a three-day hearing in Wollongong, Coroner Ian Guy heard evidence of systemic failures that led to the death of 62-year-old Anthony Rogers.Sergeant Tara Norton, assisting the coroner, called for reforms - which have since taken place at the hospital - to be implemented statewide.Mr Rogers was admitted to Wollongong Hospital on April 21, 2005, for a left hip replacement.His uneventful surgery took place at 11.50am that day and later that afternoon his wife, Sandra, said he was sore, but in good spirits.During the next two days his condition deteriorated, with his medical notes indicating Mr Rogers suffered increasing levels of abdominal pain and was retaining fluid.By 2.35am on April 24, Mr Rogers had died, with the official cause of death listed as acute aspiration following vomiting due to intestinal paralysis and left hip replacement surgery.An expert report by Dr Philip Truskett tendered to the inquest said Mr Rogers death was avoidable."Mr Rogers deterioration was gradual and not sudden, but there was failure of the provision of an appropriate level of resident and nursing staff to recognise this deterioration," Dr Truskett said in his report.The report said there was no evidence in Mr Rogers' notes that senior staff were notified of his progressive problems and that phone orders to administer drugs were made by more senior resident staff without an appropriate review of Mr Rogers' condition being made.Forensic pathologist Dr Grant McBride conducted a post-mortem on Mr Rogers on April 29, 2005, and reported that some of the drugs administered to Mr Rogers may have aggravated his condition.He also stated that no Reportable Incident Brief had been compiled despite doctors agreeing that the matter should be referred to a coroner at the time of death.Documents tendered to the coroner said a case review meeting was held at the hospital on November 22, 2005, with Mr Rogers' widow and son.At that meeting senior hospital staff recognised that there was a lack of senior medical intervention at any stage of Mr Rogers' admission and minimal recommendations for a more senior medical review by nursing staff.Decreased medical staff over the weekend, when Mr Rogers was admitted, was also a contributing factor raised at the meeting.Mr Rogers' son, Scott Rogers, gave evidence yesterday about the November meeting with hospital staff.He said the meeting ended abruptly when he asked whether some of the medication given to his father was in the category of medications his hospital notes said he was allergic to.Counsel for South East Sydney Illawarra Area Health Service Michael Fordham told the court the incident was a systems failure where no one person acted inappropriately."There has been, as a result of Mr Rogers' death, a number of changes that have taken place to prevent this happening again," he said.Those changes affected the whole area health service and included further education for hospital staff on patient deterioration and the implementation of a death notification and audit process where all deaths at the hospital were reviewed. In summing up, Sgt Norton urged the coroner to recommend to Health Minister John Della Bosca and NSW Health that the death notification and audit process be implemented in all NSW hospitals.She also asked he recommend that statewide education be provided for all medical officers on reportable incident briefs and root cause analysis investigations, and that all clinical staff be educated on identifying issues relating to deteriorating patients after surgery.Coroner Guy is expected to hand down his findings on November 10.

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