Alexander (Alex) Costello died on 9 April 2016 at the age of 37 years old. Alex arrived at the Gunnedah Hospital Emergency Department suffering chest pain.
He was diagnosed with gastritis by a general practitioner and transferred to a general ward, where he subsequently died some hours later. A post mortem revealed that Alex had suffered a Type A aortic dissection, a heart condition that his father and cousin had also experienced.
Alex arrived at the Emergency Department (ED) at Gunnedah Hospital on 9 April 2016 suffering chest pain. After conducting six and a half hours of tests, Dr Gittoes, a general practitioner and the only doctor at the ED that day, decided he was suffering gastritis.
Alex was transferred to a general ward that evening, where he subsequently collapsed while having a shower. He was unable to be revived and was declared dead at 8:56pm.
A post mortem found that Alex had suffered a Type A aortic dissection causing a rupture of the aortic into the pericardial sac causing tamponade. An inquest was held to examine the care, treatment and diagnosis that Alex received at the Gunnedah Hospital , including whether Alex should have been transferred to another hospital and whether his death was preventable.
Alex did not visit the doctor regularly as he was rarely sick. His father had survived an aortic dissection and a cousin aged 35 died from the condition in 2012. Alex was told he should see a cardiologist about this issue and that his blood pressure should be monitored. Alex did not consult a cardiologist.
Events leading up to the death of Alex
At about 1:20pm on 9 April, Alex approached his brother at football, clutching his chest with one hand. He then dropped to one knee, turning grey. He was immediately driven to the Gunnedah Hospital. On the trip there, Alex exhibited signs of severe pain, sweated profusely, lost all his colour and held his chest.
Upon arrival at Gunnedah Hospital, Alex was placed in a wheel chair, taken straight to the ED and triaged as a category 2 patient. The ED was busy, though Alex was considered the most serious case. Dr Gittoes examined Alex within a few minutes of his arrival at the ED, though he recorded his progress notes sometime later given the busy ED.
RN Sullivan asked Alex questions, but could not recall what was said regarding whether there was any family history of heart disease. RN Sullivan commenced the use of a 'Chest Pain Pathway' (CPP), a blood sample was taken to test for troponin and two ECGs was conducted, the results of which were normal. In total, approximately 30 minutes was spent attempting to diagnose Alex and address his pain.
Conversations regarding Alex's family medical history
No notes were recorded by Dr Gittoes in relation to Alex's family history. Emma, Alex's wife, attended the ER after Alex's arrival. She asserts that she mentioned he had a history of a heart condition and that she mentioned the possibility of a burst artery. She further states that Dr Gittoes requested the name of the condition, which she could not provide. RN Mainey, who was also in attendance, could recall Emma mentioning Alex's heart disease, but not the possibility of a burst artery.
The coroner noted that determining what was said of Alex's medical history posed difficulties as there were no notes taken by medical staff. As such, witnesses had to recollect what took place over 2.5 years later. The coroner concluded that it was likely medical staff were informed there was a history of a heart condition and that the term 'artery' was used', but not the term 'aorta'.
Was the treatment, monitoring and diagnosis reasonable and appropriate?
Dr Gittoes considered that Alex's normal ECGs and negative troponin test did not point to a myocardial infarction. He then considered several differential diagnoses. During his treatment of Alex, Dr Gittoes did not record times for any of his notes. As a result, there was a lack of clarity in the notes as to the clinical decisions made by Dr Gittoes.
Dr Gittoes stated that he had not heard the term 'artery' mentioned by anyone and so considered Gastritis the most likely diagnosis. Further, Dr Gittoes noted that Alex had elected to walk to the bathroom, rather than use a wheelchair. In view of this clinical improvement, Dr Gittoes decided not to contact Tamworth Hospital . Emma stated that undertaking these tasks left Alex physically exhausted.
The CPP flowchart indicates that it was appropriate in the circumstances to consider an aortic dissection. Dr Gittoes stated that he had never been instructed to use this flowchart and does not recall filling one in. Dr Gittoes further submitted that an aortic dissection in a man of Alex's age is extremely rare.
Expert evidence from Associate Professor Vincent Roche suggested that Dr Gittoes had done a very good job given his position as a general practitioner, the lack of resourcing at the Gunnedah Hospital and the rarity of the condition. Dr Roche also said that he does not utilise the CPP chart and instead relies on independent clinical thinking.
Further evidence from Associate Professor Anna Holdgate suggested that Dr Gittoes took inadequate notes in relation to the onset of Alex's pain, its nature and his family history. She further asserted that the significance of considering an aortic dissection is highlighted in the CPP flowchart and that a diagnosis of Gastritis was not reasonable and did not explain all of Alex's symptoms. Associate Professor Peter Hansen similarly opined that an aortic dissection should have been considered.
The coroner found the following factors in the treatment, monitoring and diagnosis of Alex were not reasonable and appropriate:
- Dr Gittoes notes did not include time recordings nor information regarding the onset and nature of his symptoms and his family history.
- Staff failed to properly record information provided by Alex's family that was relevant to his care and treatment.
- Dr Gittoes did not consider aortic dissection as a diagnosis, when it was reasonable to do so in the circumstances.
- The CPP was not appropriately used.
Timeline transportation to another hospital
The coroner found that an aortic dissection should have been considered. As such, Alex should have been transferred to John Hunter Hospital for treatment by a specialist surgical cardiothoracic team. The process of being transferred was determined to be as follows:
- Alex should not have been transferred from the ED to a general ward.
- Based on expert evidence, Alex should have been reviewed at 3:30pm.
- Dr Gittoes would then need to have contacted a consultant at Tamworth Hospital. It would have been unlikely that Alex could be transferred directly to John Hunter Hospital as his diagnosis had not been confirmed.
- Following a provisional diagnosis, an ambulance would need to be ready at short notice and Alex would need to be prepared for transfer and handover, and immediately driven to Tamworth Hospital . The drive would have taken 1.5 hours.
- Upon arriving at the Tamworth ED, Alex would need to be triaged and sent for CT scanning, which would take 1 hour, subject to further possible delays.
- Following diagnosis, consultation would be needed with clinicians at John Hunter Hospital. A consultant registrar would need to have been available to take the call, which might not have been possible.
- A discussion with a senior cardiothoracic surgery clinician at John Hunter Hospital would then need to take place.
- Provided a helicopter was available at Tamworth, and weather conditions permitted, Alex could have been flown to John Hunter Hospital in an hour.
- Once at John Hunter Hospital , it would take 3 hours in an optimal setting before Alex was received into theatre.
- Expert evidence indicated that the surgery itself has a 20-30% mortality rate.
Was Alex's death preventable?
Given the time it would have taken to transfer Alex, the coroner found on the balance of probabilities that it is unlikely Alex would have survived. As such, Alex's death was not preventable.
Was the NSW health policies in relation to a patient presenting with chest pain appropriate?
The Gunnedah Hospital utilises the standard NSW CPP. While the CPP was commenced by RN Sullivan and completed by RN Mainey, no one signed it. The coroner accepted that the CPP is a guide only, but noted that evidence at the inquest indicated a poor understanding of the use and responsibilities of the CPP at the Gunnedah Hospital . While Dr Gittoes is an experienced GP, he is not an experienced emergency physician and at the time had not encountered an aortic dissection. The CPP would have served as a useful guide in such circumstances.
The coroner concluded that the nursing and medical staff at the Gunnedah Hospital did not receive adequate education or have a clear understanding of whom is responsible to determine risk levels and stratification decisions in accordance with the CPP.
The coroner recommended that all nursing and medical staff at the Gunnedah Hospital ED be reminded as part of their induction and ongoing training of the importance of the clinical use of a CPP. It was also recommended that all staff be trained on their specific roles and responsibilities in the use of the CPP. Audits were recommended to ensure compliance with this recommendation.