An Illawarra mother who died at Wollongong Hospital after ongoing complications with her tracheostomy has exposed the need for health care reforms, a coronial inquest has been told.
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Andrea Lester - a mother of two who worked in retail in Lake Illawarra - died at the hospital at age 49 on June 19, 2018, two months after she suffered a rare aneurysm.
On the first day of an inquest into her death at Wollongong Local Court, Counsel Assisting the Coroner Emma Sullivan said Lester's loss was "devastating" for her family.
Lester first presented to her GP, Dr Raj Singh, in March 2018 with nausea, neck and back pain. She was diagnosed with neck strain, and was prescribed pain medication.
In providing evidence to the court on Monday, Dr Singh said he did not take note of Lester's pain history or take her temperature.
The next morning, Lester's partner took her to Shellharbour Hospital where she was triaged.
The court heard Lester was discharged shortly after and was diagnosed with muscular strain of the neck and an associated viral illness.
Lester went back to her GP on April 5 and recorded ongoing fatigue, body aches, lack of appetite, coughing and said her son had developed the flu.
Dr Singh prescribed Lester antibiotics and told her to return to hospital if the symptoms worsened, the court heard.
The next day, Lester's partner took her to Shellharbour Hospital again after he found her moaning and lying "in a ball". The court heard she was recognised at the outset as "seriously unwell".
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Subsequent CT scans revealed a subarachnoid haemorrhage - which is the bleeding in the membrane and pia mater surrounding the brain. Symptoms include headache, vomiting, fever and neck stiffness or pain.
Ms Sullivan said one of the expert witnesses, Professor Martin Krause, identified these types of aneurysms as rare, but added they can be detected with diagnostic tools when a patient complains of neck and head pain.
However, failure to diagnose would not have altered the risky treatment and did not ultimately contribute to Lester's death, the expert added.
On April 7, Lester was transferred from Shellharbour Hospital to Wollongong Hospital, where she was then airlifted to Prince of Wales Hospital to undergo emergency surgery to drain fluid from her brain.
To stop the bleeding, the surgery involved sacrificing an artery, inducing a form of stroke which impaired Lester's airways and ability to swallow.
Five days later, Lester underwent a tracheostomy procedure to aid her ability to breathe. She returned to Wollongong Hospital on May 2, 2018.
'Complex care'
The court heard the goal for patients with a tracheostomy is to wean them off the tube to gradually restore normal breathing functions.
This process requires "complex care" and a multidisciplinary team, Ms Sullivan told the court.
Lester spent three weeks in ICU at Wollongong Hospital where there were ongoing difficulties with her tracheostomy.
She was eventually transferred to a neurological high dependency unit, with the goal to wean and remove the tube.
Despite ongoing complications with the weaning process, Lester was scheduled to be decannulated on June 13.
Registered nurse Kerry-Anne Hegarty provided evidence at the inquest and said during a handover that morning, she was aware Lester was set to have the tube removed.
That day, Ms Hegarty found Lester non-responsive. She started CPR and hit an emergency buzzer, with protocols followed by doctors.
After emergency surgery, Lester was transferred to ICU. Her life support was turned off on June 19.
'Impetus for reform'
Ms Sullivan told the court the inquest's purpose was not to find guilt over Lester's death, but instead to highlight the need for reform in the local health district - particularly with staffing levels in hospitals and tracheostomy care.
"No question, the clinicians were diligent and had her best interest at heart," Ms Sullivan said. "The shortcomings are of a systemic nature and not to do with individual clinicians failings."
In giving evidence, Ms Hegarty added the hospital would benefit from a specialised tracheostomy role given one patient with a tracheostomy presents to the hospital every six to 12 months.
"It would be great to have that extra education when we have trach patients, it is hard to maintain skills when you see them so infrequently," Ms Hegarty told the court.
The inquest continues, with witnesses evidence to be provided from experts and a speech pathologist in the coming days.
It is expected to wrap up Friday.
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