The ‘‘coincidental alignment’’ of a series of oversights and questionable decisions made at Wollongong Hospital largely contributed to the death of Mount St Thomas grandfather Ariel Vega on an August evening two years ago, an inquest has heard.
The 78-year-old went missing from the hospital’s Ward Three East about 6.30pm on August 8, 2011, after having minor surgery earlier that day.
He was found dead 17 hours later, having broken his neck after falling face down through an aluminium-framed window within a plant room in a restricted part of the hospital.
The events leading up to and including Mr Vega’s death have been the subject of a two-week inquest in the Coroner’s Court in Wollongong.
During closing submissions yesterday, counsel assisting the coroner, Peter Aitken, said the series of events that day, including the absence of important parts of Mr Vega’s medical history during pre-admission checks, had ‘‘a clear and direct contribution’’ to his death.
The court previously heard nurses charged with Mr Vega’s post-operative care were not told he had suffered from a ‘‘delirious episode’’ after surgery in 2008.
At the time, Mr Vega became distressed, disoriented and combative, and had to be given a powerful anti-psychotic drug.
A nurse who looked after him before he went missing in 2011 said if she had been told of the earlier incident, she would have looked out for any early signs of delirium.
Mr Aitken yesterday argued that the hospital should have known Mr Vega was at risk of having a delirious episode based on his own medical history and the prevalence of such episodes in older patients – about three in every 10 admitted to the hospital.
He said Mr Vega’s ‘‘illogical’’ behaviour while in the ward and the observations of staff shortly before he went missing was ‘‘powerful evidence’’ that he was ‘‘suffering from delirium or at least, significant confusion’’.
Meantime, Mr Aitken also took aim at the ‘‘haphazard’’ nature of the search for Mr Vega after his disappearance, saying the protocol that existed at the time was inadequate.
However, he did acknowledge that the hospital had since made radical changes to its search procedures, including having an appointed search co-ordinator, and opting for an ‘‘outwards’’ approach, meaning staff began their search from the point where the patient was last seen.
Mr Aitken put forward a series of recommendations for Magistrate Beattie to consider.
Among the suggestions were better pre-admission assessment of patients to detect an increased risk of delirium; an alert be set up on the hospital’s computer patient records warning of previous episodes of delirium and better training for staff to identify signs of delirium.
Lawyers for the Vega family and the Illawarra Shoalhaven Local Health District will give closing statements to the court today.