Mr Leonard Bartholomeusz died at the Prince of Wales Hospital in New South Wales after he was transferred from the Sydney Hospital for a hip operation.

Prior to his death, Mr Bartholomeusz underwent some tests which revealed that he had a heart condition. However, given a possible lack of communication of the results of these tests, the Prince of Wales Hospital proceeded to provide the deceased with treatment related to his hip injury. The inquest into his death examined the circumstances in which he died and the care and management he received from both hospitals.

Background Facts

On 30 April 2013, the deceased went to a supermarket to buy groceries when he had a fall. Paramedics were called and when they arrived, found that the deceased had limited range of movement in his left shoulder and a small laceration to the bridge of his nose which was bleeding. He was taken to Sydney Hospital.

After a review by the doctor, a view was formed that the deceased had a dislocated shoulder. A reduction was made on his shoulder. Shortly after this, nursing staff reported that the deceased experienced pain in his left hip. An x-ray was conducted in that area which revealed that he had hip fracture. Since the Sydney Hospital did not have an orthopaedic department, the treating doctor made arrangement for the deceased to undergo surgery at Prince of Wales Hospital ('POWH'). Preparations for this surgery included blood tests and an electrocardiogram ('ECG'). The first ECG was performed before transfer to POWH and was not considered to be significant. The result was not available to POWH who proceeded to have three additional ECGs. The additional ECGs indicated that the deceased had suffered a form of heart attack.

On 1 May 2013, the deceased's vital signs were noted to be stable. The hip operation proceeded without complication. However later that day, the deceased was noted to be confused, delirious and disorientated. As a result of this, he was given antipsychotic and benzodiazepine medication overnight. Episodes of agitation continued, leading to the deceased being transferred to the Acute Aged Care Extension Unit for further management on 6 May 2013. Around 7.15pm that day, the deceased complained of feeling hot and nurses began to help him remove his jacket. As this was happening, he slumped and became unresponsive. He could not be resuscitated and was pronounced dead at 8.24pm, aged 73.

An autopsy revealed that the deceased died due to consequences of myocardial infarction on the anterior aspect of the heart, with coronary artery atherosclerotic disease as an antecedent cause. The inquest heard that myocardial rupture is a well-known complication following a heart attack. The inquest examined the care and management the deceased received prior to his death.

Findings

Treatment at Sydney Hospital

The treating doctor from this hospital submitted that the result of the deceased's first ECG was non-specific and partly affected by him being agitated. He also submitted that the deceased was not displaying any signs of chest pain or any cardiac related symptoms. As a result, he did not consider any further investigations prior to the transfer to POWH. Submissions of other experts generally supported this. The Coroner accepted that the treating doctor at Sydney Hospital did not act contrary to generally accepted medical practice.

Treatment at POWH

The Coroner found that on the evidence of the records from POWH, there was no way of determining who performed the additional ECGs and whether they were brought to the attention of any clinician. He said that given the critical diagnostic importance of these ECGs, it is important that POWH organise its processes better to avoid a recurrence in the future. The Coroner further stated that if the ECG at the POWH had been made known to the deceased's treating doctors at POWH, the deceased would have been admitted to the coronary care unit and an angiogram performed.

However the Coroner noted that any cardiac treatment could have precluded the urgent surgery the deceased needed performed on his hip. Therefore, any decision made either way, would have been with careful consideration by a team of medical experts. The Coroner found that it was not possible to know for certain that a cardiac treatment would have yielded a different outcome.

The Coroner further found that even though there was evidence to show that the deceased's myocardial infarction was a possible cause of his delirium, there was other evidence to show that it is not unusual for patients to have delirium a few days after surgery. He found that there was no evidence to support the view that the investigation conducted by the treating team regarding the delirium was inadequate or incomplete.