Background Facts

A GP, Dr IK attended upon Mrs MDF at her home, where Mrs MDF was recorded to be experiencing abdominal pain. Dr IK administered Tramadol and Maxolan intramuscularly. Mrs MDF was then referred to Public Hospital to determine the cause of the generalise tenderness in her abdomen that she was experiencing. In transport, QAS recorded Mrs MDF to be hyperventilating and very demonstrative with her pain on their arrival. Mrs MDF was administered morphine and methoyflourane intravenously.

The Emergency Department's records revealed that Mrs MDF was administered IV fluids and given IC morphine and fentanyl. Blood tests also revealed abnormal bicarbonate, anion gap, glucose, urea, creatinine, GFR, bilirubin, aspartate transaminase and osmolality.

An urgent CT scan was initially without contrast but converted to contrast as there was concerning features of abdominal pain on the non-contrast CT scan. Dr TG's records show that he perceived Mrs MDF to be clinically dehydrated and queried whether she had an ischaemic gut. The surgical registrar, Dr SK was notified and would review Mrs MDF. Mrs MDF was admitted and then underwent an emergency laparotomy after CT scans suggested an ischaemic bowel and collapsed inferior vena cava (indicating profound shock).

Mrs MDF's condition did not improve port-operatively and treatment was withdrawn. She unfortunately died on 30 November 2016.

Root Cause Analysis

A Root Cause Analysis (RCA) was commissioned on 23 August 2017.

The RCA noted Dr SK's initial view that Mrs MDF required surgical intervention however Dr RK believed it was ischaemic bowel and required conservative management.

The RCA made the following comment:

'It was noted however that the diagnosis of ischaemic colitis was not likely given the extent of bowel involvement on the CT and the metabolic derangement which would suggest more extensive bowel ischaemia was present at presentation. This discordance may have been detected earlier if the consultant surgeon had reviewed the patient personally.'

The RCA was critical of Dr SK recording 'please notify if clinically deteriorating' for not being a clear set of parameters to indicate when Mrs MDF would need surgery. There should have been involved discussions with Mrs MDF in relation to the risks and benefits of surgery.

The inconsistency between Mrs MDF's clinical status and actual condition was inconsistent between Dr SK and Dr NA's assessment. This was attributed to a lack of clear management strategies inclusive of escalation parameters and triggers for Mrs MDF.

The RCA made the following recommendations:

  • medical officers in the surgical division should be reminded of their professional standards and expectations; and
  • The ICU to operate as an extension to Gold Coast University Hospital's level 6 ICU and cross campus ICU Director with Deputy ICU directors at each site.


The clinical care provided by Dr SK and Dr NA were deficient for failing to escalate Mrs MDF's deteriorating condition that required surgical intervention. The RCA also concluded that Dr AM and Dr RK's supervision of Dr SK and Dr NA may have also been deficient. Dr AM and Dr RK should have reviewed Mrs MDF and/or documents a clear management plan to manage Mrs MDF's condition.

The cause of death was a multisystem organ failure due to or a consequence of ischaemic small intestine and colon. Coroner James McDougall concluded that it would not be in the public interest to proceed to inquest.