The inquest into the death of Edward Mayell, who died from pneumonia and severe acute respiratory distress syndrome complicated by septic shock, is a reminder of the importance of timely and clear communication between GPs, hospitals, and radiologists.

Background

Mr Mayell died on 5 2014 from pneumonia and severe acute respiratory distress syndrome, caused by the bacterium Legionella. He was 83 years of age at the time of his death, which was the subject of a coronial inquest.

Mr Mayell had an extensive medical history which included ischaemic heart disease, a coronary artery bypass, atrial fibrillation, congestive cardiac failure, and chronic obstructive pulmonary disease.

At relevant times, Mr Mayell consulted his local general practitioner, Dr Sewart at the Beachport Medical Centre (Centre). It is significant, for reasons which will become apparent, that the Centre was closed and unattended on Tuesdays and Thursdays. It is also significant that, during these periods, there were no procedures in place to ensure that Dr Stewart could be contacted on these days.

Mr Mayell presented to the Centre feeling unwell on Friday 12 September 2014. Blood testing was arranged. His condition deteriorated over the weekend and on Monday 15 September 2014, he re-attended the Centre at which time his test results were confirmed to be abnormal, likely the result of pneumonia.

Mr Mayell was referred to Millicent Hospital on the morning of Tuesday 16 September 2014, at which time a chest x-ray was performed. Mr Mayell was discharged by Dr Hagan, a locum at the hospital, before the results were to hand.

The chest x-ray was reported on later that evening, and it confirmed the diagnosis of pneumonia although the pathogen was not clear. Notwithstanding the fact that Dr Hagan reviewed the results that evening, no steps were taken in respect of the report at that time. Nor did the radiologist take any steps to ensure that Dr Hagan or Dr Stewart were aware of the results.

As the Centre was closed that day, Dr Stewart reviewed the report on the Wednesday morning, erroneously concluding upon its review that Mr Mayell was suffering from pneumonia caused by aspiration of stomach contents into the lungs (as opposed to community acquired pneumonia).

Mr Mayell was transferred back to Millicent Hospital, where he was given antibiotic therapy, but with aspiration pneumonia in mind. That antibiotic regime was not sufficiently broad in its spectrum so as to cover Legionella. In addition, therapy was not started until 4 pm that afternoon, despite the diagnosis of pneumonia having occurred the day before. It was not until Mr Mayell’s transport to Mt Gambier Hospital later on Wednesday evening that an appropriate broad spectrum antibiotic regime was administered.

Mr Mayell subsequently died as a result of the infection.

Findings

The Coroner was critical of the conduct of the professionals involved in Mr Mayell’s care. Of note, the Coroner concluded that:

• The radiological report which confirmed the diagnosis of pneumonia, indicating the need for urgent medical attention, ought to have been drawn to the attention of both Dr Stewart and Dr Hagan as soon as it was created. In this regard, it was incumbent upon the reporting radiologist to have telephoned both practitioners. The absence of procedures in place at the Centre to ensure that urgent results could be communicated on a day of closure was also criticised.

• Both Dr Stewart and Dr Hagan had an independent obligation to inform themselves of the results of the radiological examination at the earliest opportunity and to take the necessary action in response.

• The treatment received by Mr Mayell at the Millicent Hospital was also unsatisfactory in circumstances where, among other things:

- Mr Mayell was not closely monitored despite significantly low blood pressure on presentation;

- Mr Mayell was discharged before the results of the x-ray were to hand;

- Dr Hagan took no steps to contact Mr Mayell or Dr Stewart when (at approximately 10pm that evening) she reviewed the results of the x-ray; and

- it was noted that Dr Hagan may also have been unduly influenced by Mr Stewart’s view that Mr Mayall had aspiration pneumonia, contributing to the inappropriate antibiotic therapy initially arranged.

As a result of Mr Mayell’s comorbidities, the Coroner could not conclude that earlier appropriate antibiotic treatment would have prevented his death. However, on the balance of probabilities, Mr Mayell’s chances of survival would have been higher.

Numerous recommendations were made by the coroner, including that:

• steps ought to be implemented to ensure important radiological and pathology results are drawn to the attention of the referring medical practitioner as soon as they are received; and

• the practice manager of the Centre must ensure that there is a clear and robust understanding between the Centre and the Millicent and Mt Gambier hospitals in relation to the transmission of important information regarding patients. 

Comment

Mr Mayell’s death is a reminder of the importance of ensuring that patient results, in particular those disclosing serious medical conditions, are communicated quickly and through appropriate means to those in decision making roles. It is also a reminder of the obligation on medical practitioners to actively inform themselves of the results of such testing at the earliest opportunity and to take the necessary action in light of those results.