Coroner calls for hospital changes

Deputy State Coroner Geraldine Beattie yesterday recommended the Illawarra Shoalhaven Local Health District implement a series of changes to its pre-surgery admission protocols and record keeping, following the death of Mount St Thomas man Ariel Vega in 2011.

Mr Vega had been admitted to the hospital on the morning of August 8, 2011, for routine surgery, however he went missing from his bed about 6.30pm while recovering in a general ward.

Nurses and security staff launched an extensive search for the missing 78-year-old in the hospital grounds and nearby streets, but failed to locate him.

He was eventually found dead 17 hours later, having broken his neck  falling face down through an aluminium-framed window within a plant room in a restricted part of the hospital.

Ms Beattie ruled Mr Vega’s death was ‘‘both tragic and avoidable’’, saying it had been the result of a combination of various ‘‘systems issues’’ within the hospital rather than any single error, omission or issue.

She found Mr Vega’s behaviour in the hours leading up to his death strongly suggested he was suffering an episode of delirium, which he experienced previously following surgery in 2008, but had not been recorded on his medical file for future reference.

She said although Mr Vega had not shown any signs of dementia-related illness during pre-admission stage, the absence of adequate information on his file about the 2008 episode presented a ‘‘lost opportunity’’ for staff to assess the risk of him suffering post-operative delirium.

Ms Beattie recommended the Illawarra Shoalhaven Local Health District carry out screening tests for signs of dementia-related illness on all patients aged over 70.

She also called for any prior episodes of delirium to be flagged as alerts on patient’s records.

Family glad dad's death not in vain

THE family of Mount St Thomas man Ariel Vega say he would have been proud to know they fought in his memory for changes to Wollongong Hospital’s protocols.

Mr Vega tragically died after breaking his neck when he fell through an internal window contained in an out-of-the-way plant room within a restricted area at the hospital on August 8, 2011.

Mr Vega had earlier gone missing from the hospital’s Ward Three East about 6.30pm following minor surgery that morning.

He accessed an atrium area and a plant room beside it through  two sets of doors. The doors were unlocked at the time –  a breach of hospital security protocol.

He was found dead in the plant room the next morning, having fallen and broken his neck.

Yesterday, Deputy State Coroner Geraldine Beattie found Mr Vega had been suffering an episode of delirium when he walked off the ward and ultimately to his death.

She acknowledged the hospital had already made significant changes to its practices and protocols after Mr Vega’s death, however, she recommended further changes to its pre-admission assessments of patients, including better assessing patients who might be at risk of experiencing post-operative delirium.

She also recommended better procedures when searching for missing patients.

Mr Vega’s son,  Henry, speaking on behalf of his family yesterday, said they were relieved the inquest was over.

‘‘We are quite happy with the findings, obviously there’s been a lot of changes already at the hospital and there will be more changes to prevent this kind of thing happening again,’’  Henry Vega said.

‘‘I’m pretty sure my father would be very pleased to see we’re going through this struggle, that we’re fighting for him...for what happened to him.

‘‘I guess it means our father’s death wasn’t in vain.’’