Mr Mettaloka Malinda Halwala was a 58 year old man who died from complications of chemotherapy. Prior to his death, a test result had indicated that he suffered from toxicity resulting from this treatment. This result was not made available to the treating hospital before Mr Halwala was given another dose of chemotherapy and he died three days later.
At the time of his death, the deceased was living in a hotel in Tatura where he moved to, to be close to his work as a civil engineer at Goulburn Murray Water.
On 17 September 2015, the deceased underwent a Positron Emission Tomography (PET) scan at the Austin Hospital in Melbourne. This scan revealed metabolically active extensive Hodgkin's lymphoma involving multiple lymph nodes stations on both sides of the diaphragm and splenic and widespread marrow involvement.
From 18 September 2015 to 13 November 2015, the deceased received Adriamycin, Bleomycin Vinblastine and Dacarbazine (ABVD) chemotherapy. On 11 November 2015, the deceased underwent a PET scan at the Austin Hospital. This scan was ordered by haematologist Dr Robin Filshie. The report of this scan was prepared by Dr Sze Ting Lee. This report indicated that the deceased may be suffering from toxicity to his chemotherapy.
As at 13 November 2015 (the day the deceased was due for his next dose of chemotherapy), there had been no communication of the report of the PET scan between Dr Lee and Filshie, nor between Dr Filshie and the Goulburn Valley Hospital where the deceased was scheduled to have his next dose of chemotherapy. As a result of this, the hospital proceeded to administer another dose of chemotherapy to the deceased.
On 16 November 2015, the deceased telephoned Dr Filshie and reported that he was feeling unwell. Dr Filshie advised him to go to the hospital. Several hours later, Dr Filshie read the deceased's PET scan from 11 November 2015. He did not contact the deceased. This was, as he said, because he assumed that the deceased would have gone to the hospital as he advised. The inquest also heard that Dr Filshie did not telephone the Goulburn Valley Hospital to confirm this.
The deceased was found dead the following morning in his hotel room bed. An autopsy confirmed that his death was caused by complications of chemotherapy for the treatment of Hodgkin lymphoma.
Evidence of Dr Tse Ting Lee
Dr Lee stated that lung toxicity was a recognised complication of the ABVD therapy. However, she was of the view that Dr Filshie should have used the results of the PET scan to determine future treatment of the deceased. She also expected that Dr Filshie would confer with her before chemotherapy was continued.
Further, Dr Lee stated that Dr Filshie should have called the Austin Hospital to obtain a copy of the PET scan if he did not receive a copy before the next scheduled chemotherapy. She added that she 'might have' telephoned Dr Filshie if she knew that the deceased was to have chemotherapy two days from the day of the PET scan.
Evidence of Dr Robin Filshie
Dr Filshie acknowledged that he would have preferred to receive the PET report before the deceased had his next dose of chemotherapy. He stated that if this had happened, he would have 'without doubt' withheld treatment.
He further noted that the PET scan was only a prognostic tool and does not equal a clinical diagnosis.
Dr Filshie admitted that, not contacting the Goulburn Valley Hospital on 16 November 2015, meant that the hospital could not take the PET scan into account even if the deceased came to the hospital that day. However, he stated that there was no indication at the time, that the symptoms the deceased experienced when he telephoned his practice on that day, were related to the result of the PET scan.
Findings and Recommendations
Coroner Rosemary Carlin found that the death of Mr Halwala may have been prevented if the results of the PET scan had been conveyed to Dr Filshie before the deceased underwent his last chemotherapy on 13 November 2015.
The Coroner found that there is a 'significant disconnect' between the expectations of Dr Lee and that of Dr Filshie in relation to the way in which the deceased's results should have been communicated.
The Coroner found it surprising that Australian professional associations and hospitals do not have more 'comprehensive and explicit standards and guidelines as to the communication of test results'. This calls for a review of the Australian system.
The Coroner recommended that the medical profession consider making test results available to patients and their GPs where appropriate. In this case, the deceased as an educated man, would have done something about his test result if he had received it before undergoing another dose of chemotherapy on 13 November 2015. Similarly, a GP may have intervened if he or she received the report prior to that day.