Nicholas Wells, 24 years old, died at John Hunter Hospital, Newcastle on 23 May 2016 due to sepsis from faecal fluid entering his abdominal cavity after he sustained a bowel perforation the previous day from a motor vehicle accident.

On 22 July 2019 the Coroners Court of NSW delivered findings critical of the care and treatment from medical and nursing staff.

Background Facts

On 22 May 2016, Mr Wells’ car veered off the western edge of the Pacific Highway near Sydney and collided heavily with two posts. When ambulance officers arrived, Mr Wells was conscious and complaining of pain in numerous areas, including his lower left abdomen. Blood samples showed the presence of methamphetamine, amphetamine and cannabis metabolites.

Mr Wells was taken by the ambulance to John Hunter Hospital, Newcastle. As a designated Major Trauma Centre, the hospital was expected to provide an immediate response by a surgical registrar to a newly arrived trauma patient. However, the surgical registrar with that responsibility at the time, Dr Kusyk, did not review Mr Wells until some hours had elapsed.

Dr Kusyk, an International Medical Graduate employed as an unaccredited surgical registrar, gave evidence that he had not received the trauma call to review Mr Wells. Dr Kusyk’s eventual medical review of Mr Wells identified a possible diagnosis of small bowel injury and documented a management plan which failed to direct further surgical assessment despite the suspicion of a life-threatening condition. Dr Kusyk was subject to Level 1 Supervision and required to immediately discuss his diagnosis and management plan with his supervisor, Dr Koshy, but failed to do so.

When Dr Kusyk ultimately discussed Mr Wells with Dr Koshy, he stated, according to Dr Koshy, that Mr Wells was 'stable' and that he was not worried about Mr Wells. Further, he failed to inform Dr Koshy of Mr Wells' suspected small bowel injury or the L2 fracture. As a result of this conversation Dr Koshy decided that there was no need to personally review Mr Wells.

The Coroner noted that Dr Kusyk did not review Mr Wells, enquire as to his progress or review his clinical notes at any point after his first review. Apart from a review by a first year resident medical officer, Mr Wells was not seen by any member of the surgical unit between Dr Kusyk’s review earlier that day and when Mr Wells was found unresponsive fourteen hours later.

During this period Mr Wells’ condition continued to deteriorate and he was very agitated from insufficient pain relief and drug withdrawal symptoms. Enrolled Nurse Gardiner was assigned to nurse Mr Wells on a 1:1 basis. EN Gardiner had been an Enrolled Nurse for 18 months, had not received any training on carrying out 1:1 nursing and gave evidence that she did not understand that she was required to monitor Mr Wells for clinical deterioration. She seated herself outside his room and looked in intermittently to observe him. Once his agitation appeared to have settled she entered Mr Wells' room and saw his colour was unhealthy and his body rigid. He was pronounced deceased around 40 minutes later.

An autopsy found the cause of death to be faecal peritonitis, from a leak of faecal contents from a perforation in the small bowel. The appearance of the bowel surface indicated the perforation had occurred many hours prior to death, likely around the time the motor vehicle accident occurred.

Was the management plan appropriate?

Expert opinion unanimously held the management plan of Dr Kusyk was wholly inadequate and demonstrated poor clinical judgment as it failed to reflect the seriousness of the suspected injury. In cases of traumatic bowel injury the only accepted treatment is surgical repair. Dr Kusyk was criticised for failing to immediately discuss his finding with Dr Koshy after his review as the seriousness of the diagnosis warranted prompt discussion with a consultant to obtain a definitive diagnosis and settle a treatment plan. The Coroner considered that the manifest deficiency of the plan, combined with other deficiencies in care which followed, resulted in Mr Wells being left to deteriorate without the treatment he needed to save his life.

Should Mr Wells have been reviewed by a surgical consultant? If so, why didn’t this happen?

Experts were unanimous that the serious nature of his provisional diagnosis required almost immediate review by a senior surgical clinician. Dr Koshy, surgical consultant, did not review Mr Wells as Dr Kusyk had failed to inform of two features critical to Mr Wells’ condition, his L2 fracture and his persistence of abdominal pain. Further, Dr Kusyk had stated Mr Wells was stable despite not reviewing Mr Wells, or receiving any information about his progress, for eight hours. Nevertheless, the Coroner considered that Dr Koshy did not do enough to satisfy himself that Mr Wells did not require personal review or that the management plan was appropriate.

The nursing care provided under the 1:1 arrangement

The evidence indicated EN Gardiner’s management of Mr Wells did not comply with critical requirements which applied to such arrangements, including failing to undertake at least hourly assessments and observations of his condition and not remaining in the room with him.

Action regarding the conduct of Dr Kusyk

Dr Kusyk’s evidence did little to indicate to the Coroner an acknowledgement of the shortcomings in his care of Mr Wells, or the role in the death. The Coroner considered whether to refer the evidence heard at the inquest to the Medical Council of NSW. The Coroner decided against this course on the basis that Dr Kusyk was working in a position whose responsibilities exceeded those for which he was capable, and AHPRA, following Dr Kusyk’s self-notification, concluded the incident was a one-off and imposed a condition on Dr Kusyk’s registration requiring him to undertake and complete an education course in communication.

Recommendations

The Coroner’s recommendations included:

  1. The Hunter New England Local Health District (LHD) consider creating a policy document that no International Medical Graduate subject to Level 1 supervision be appointed to a position beyond that of an intern.
  2. The LHD consider creating a policy document specifying whether International Medical Graduates subject to different levels of supervision are eligible to be appointed to intern, resident or registrar positions within the LHD.
  3. The LHD consider creating a policy framework to govern the way International Medical Graduates are supervised and monitored, including a system to ensure their supervision requirements are communicated to the senior medical staff who provide their supervision.
  4. The LHD consider providing training and education to medical staff at the hospital in relation to the need to complete the Standard Audit General Observation Chart where a medical officer wishes to prescribe a specific frequency of observations.