Background Facts

DH, an indigenous 56 year old man, became ill in early January 2014 after cutting his left big toe on an oyster shell. Several days later after swimming, his toe became infected. His medical history included Type 2 diabetes, heart surgery in 2007 and having a defibrillator inserted in 2008.

On 21 January 2014, DH presented to Bawrunga Medical Centre who referred him to Dubbo Base Hospital. DH's wound was cleaned, checked and bandaged at the Emergency Department and he was given IV antibiotics before being discharged with oral antibiotics.

On 28 January 2014, DH attended his GP who sent him to Dubbo Base Hospital again where he was admitted. Two days later he was reviewed by a general surgeon who decided DH's toe required debriding. The operation was performed on 31 January by Dr Rice under general anaesthetics provided by Dr Ismail. While the procedure was considered a success, DH never regained consciousness. After discovering DH's oxygen levels had dropped, Dr Ismail removed the laryngeal mask and attempted to use a bag and mask to assist with DH's breathing. Another anaesthetist came to assist and noticed that DH's heart was not pumping any blood. CPR was commenced, adrenaline was administered and DH was intubated. A defibrillator was used as DH was in ventricular tachycardia to attempt to reset the heart rhythm. It was only at this stage when Dr Ismail noticed on the notes that DH had a defibrillator inserted in his chest.

DH's circulation returned and he was transferred to ICU. After 24 hours, despite the return of cardiac and respiratory function, clinical signs indicated DH had suffered a non-reversible hypoxic brain injury. On 4 February, DH was transferred to Nepean Hospital. His life support was turned off on 6 February 2014, however his defibrillator was not deactivated. The defibrillator attempted to restart DH's heart, which resulted in his body being lifted off the bed while in the presence of his family.

Following review, Dr Ismail was suspended from duty and the Medical Council of NSW imposed practice conditions on his registration. The Professional Standards Committee (PSC) Inquiry subsequently found that Dr Ismail engaged in unsatisfactory professional conduct. DH's full medical history was not obtained prior to surgery and the medical file was not fully reviewed. Further, the PSC Inquiry found Dr Ismail's treatment was inadequate in the following ways:

  • use of a laryngeal mask airway supreme instead of intubation;
  • use of total intravenous anaesthesia with propofol, which was not appropriate anaesthesia given DH’s other co-morbidities;
  • failure to adequately monitor blood pressure;
  • failure to recognise low oxygen readings, low heart rate and that DH was in pre-cardiac arrest;
  • slow response time to DH’s deteriorating condition.

Dr Ismail was reprimanded in the strongest possible terms and a series of conditions were imposed upon her registration.


The evidence received at the inquest established that DH’s cause of death was hypoxia and cardiac arrest with contributing conditions of ischaemic heart disease, diabetes mellitus and morbid obesity. The failure to properly assess his condition prior to surgery and a failure to use appropriate anaesthetic and intubation contributed to DH’s death. Dr Ismail further failed to properly monitor and respond to DH’s deteriorating condition during the procedure and this impacted on DH’s chances of recovery. The Coroner found that DH’s death was therefore preventable.

The Coroner was unable to make any finding as to why the defibrillator was not disconnected at Nepean Hospital after the decision was made to withdraw life support.

A number of out-patient services were available to DH, and the number and structuring of these services has improved since 2014. These services provide patients, including rural patients, with wound dressing and education about diabetes and wound care. The Coroner did not consider it necessary to make any recommendations regarding the disposition of these resources in the circumstances where state funding had increased since DH's death.

The Coroner was satisfied that the changes made by Dubbo Base Hospital had addressed the circumstances that led to DH undergoing surgery without a properly reviewed pre-operative anaesthetic assessment. These changes included:

  • the introduction of electronic medical records;
  • the introduction of the pre anaesthetic assessment protocol, which requires patients to be seen and reviewed by an anaesthetist and approved for surgery before they are accepted on a theatre list. Following review, if a patient has a rating of ASA 4 or 5, the patient must be discussed/reviewed with the anaesthetic consultant in charge; and
  • a hospital policy of ‘speaking up for safety’.

DH’s family requested a recommendation be made to the Health Service to fund more Aboriginal Health Workers (AHW). The Coroner considered the current action to recruit more aboriginal staff overall, whilst still attempting to fill the newly created AHP position, was appropriate.