A coroner has strongly criticised the Illawarra Retirement Trust and referred two Wollongong doctors to the Health Care Complaints Commission following the death of an elderly woman.
Jean Boyd died at Wollongong Hospital on October 7, 2009 following severe complications from a urinary tract infection.
The 88-year-old, cared for in the IRT’s William Beach Gardens, was only taken to hospital at the insistence of her family six days after the infection was first diagnosed. She died three days later from E.coli septicaemia and congestive cardiac failure caused by respiratory distress and acute renal failure.
Handing down her findings in Wollongong Local Court yesterday, Deputy State Coroner Geraldine Beattie found Mrs Boyd’s death was ‘‘most likely, avoidable’’.
She said Mrs Boyd’s deteriorating health and the critical nature of her condition were not sufficiently responded to by IRT staff and that their notes were deficient.
She also recommended the Department of Health and Ageing conduct a review of the ratio of nursing staff to high-care residents at the home.
Mrs Boyd’s general practitioner, Dr Myrna Jover, prescribed antibiotics on September 30 but the medication was not given until the morning of October 2.
By that stage Mrs Boyd was gravely ill and suffering from delirium and dehydration.
The coroner found attempts to administer the medication and fluids by IRT staff were ‘‘clearly not sufficient’’.
By October 1 her urinary tract infection was accompanied by ‘‘significant markers of deterioration including fluctuating levels of consciousness, sleepiness and intermittent confusion’’.
The coroner criticised the IRT, saying its staff had not detected the bigger picture of Mrs Boyd’s condition.
‘‘It appears instead they (staff) were picking up the individual symptoms at a particular point in time rather than the developing picture of Mrs Boyd’s illness. This impacted on the staff’s ability to monitor her condition and to readily detect any deterioration,’’ Ms Beattie said.
The inquest heard that on October 3 Ms Boyd was screaming in pain when staff attempted to move her, but she was not seen by the registered nurse on site until the Radio Doctor, Dr Deepak Raja, had arrived seven hours later.
Ms Beattie said Ms Boyd needed to have been taken to hospital at the latest on October 1, three days earlier, to be given adequate care including intravenous medications and fluids.
‘‘If that had occurred it is entirely possible that her death could have been avoided or delayed,’’ the coroner found.
In referring the two doctors to the Health Care Complaints Commission, Ms Beattie said Dr Jover had failed to read Mrs Boyd’s progress notes and failed to appreciate her symptoms of delirium.
‘‘It appears that Dr Jover formed the mistaken view that this was simply a normal urinary tract infection, which would go away after a few days of antibiotics,’’ the coroner said.
She said Dr Jover had failed to follow up on her patient to check if she was responding to treatment and had not provided instructions to IRT staff regarding her care.
She also referred Dr Raja for not making notes of his examination of Mrs Boyd and his failure to instruct nursing and care staff. She also found he too had not reviewed the notes made by staff and if he had he would have seen Mrs Boyd had very low fluid intake and had an alarmingly low temperature six hours before.
‘‘It is apparent from all the evidence that Dr Raja did not appropriately examine and treat her,’’ the coroner said.
She recommended that the IRT review the communication between doctors and IRT care staff and nurses regarding the treatment of acute illnesses and that appropriate protocol be put in place with regards to the identification and management of deterioration in the condition of its aged-care residents.
She said though some improvements had been and were still being made by IRT, the system deficiencies that failed Mrs Boyd had not been ‘‘sufficiently addressed’’, primarily in staffing, training and internal investigation following critical incidents.
IRT general manager lifestyle and care Craig Smith said they were currently reviewing the coroner’s report.
‘‘We express our sympathies to the family of Mrs Boyd.
‘‘William Beach Gardens has already acted on some of the coroner’s recommendations and is supportive of and committed to putting in place any additional action.”