Man admitted to hospital for elective surgery dies a month later after failure by medical staff to identify cause of abdominal pain.
Inquest into the death of Mark Anthony Plumb
Inquest Dates: 6 April 2016, 27-29 July 2016
Coroner: John Lock
Date of Death: 23 October 2014
Issues for Consideration:
- Whether the surgical procedure conducted by Dr Pitre Anderson was appropriate.
- If the post-operative care provided to Mr Plumb at the Friendly Society Private Hospital was appropriate, including whether the staff recognized and responded appropriately to the deterioration of his condition.
- Whether there was a timely recognition of the need to transfer Mr Plumb to the Wesley Hospital for urgent surgical management.
- Friendly Society Private Hospital
- Dr H Gabruseva
- Dr Pitre Anderson
On 19 September 2014, Mark Plumb, aged 76, attended the Friendly Society Private Hospital for an elective procedure with Dr Pitre Anderson for an endoscopy (‘ERCP’), sphincterotomy and gall stone extraction. Following the surgery, Mr Plumb began to experience severe pain in his abdomen. A CT scan later that evening indicated that his bile duct may have been perforated during the surgery. A conservative management plan was implemented by Dr Anderson.
Mr Plumb’s condition deteriorated overnight, and he became septic. It was determined the following day that he should be transferred to the Wesley Hospital in Brisbane for urgent care. Despite the measures taken by the Wesley Hospital, Mr Plumb remained critically unwell. He passed away on 23 October 2014.
Evidence of the Parties
Evidence of Dr Pitre Anderson, Treating Specialist General Surgeon
- When he received the call with the CT results, he was told that there was no free intraperitoneal fluid.
- Had he been informed of Mr Plumb’s condition at 0215 hours on 20 September 2014, he would have attended the hospital. Upon seeing his condition, he would have arranged for his immediate transfer from the hospital.
Expert review of Dr Phil Lockie, Specialist General Surgeon
- It was unreasonable that Dr Anderson, in light of the CT results and rise in Mr Plumb’s lipase level, did not review Mr Plumb or institute any changes to his management. The CT results indicating the presence of retroperitoneal fluid should not have been reassuring even if there was no intraperitoneal fluid.
- The failure by the nursing staff and/or residing medical officer to contact Dr Anderson at 0215 hours was not appropriate. Recommended that this be investigated by disciplinary or regulatory authorities.
- Based on their location in Bundaberg, it would have been appropriate for Dr Anderson to discuss Mr Plumb’s condition with a Hepatobiliary Surgeon when he became aware of possible complications from the ERCP at 2125 hours. Such a discussion could have confirmed for Dr Anderson his approach, given that perforations during an ERCP are rare.
- The Hepatobiliary Surgeon should then have been contacted again at 0215 hours when it was determined that Mr Plumb was deteriorating further, and he would have been transferred to a specialist unit sooner.
Clinical review by Friendly Society Private Hospital (‘FSPH’)
- ERCPs are no longer performed at the FSPH.
- An Acute Pain Management Policy was developed to ease clarity with pain management principles hospital-wide.
- An opportunity to escalate Mr Plumb’s treatment and prevent further deterioration of his condition was missed when Dr Anderson did not physically review him following the CT scan. This could have highlighted his need for escalated management, and potentially prevented his death.
- Wherever possible, the Friendly Society Private Hospital should continue to conduct Root Cause Analyses following incidents.
- Dr Anderson’s behavior was not referred to the disciplinary body as he retired in January 2015 and is unwell.
Chronology of Events
|Mark Anthony Plumb, aged 76, is admitted for surgery for an elective endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for gall stones.|
|0849 hours||Mr Plumb was returned to the recovery room following surgery. He began complaining of pain and discomfort in his abdominal area, and was prescribed IV Panadol and morphine.|
|1200 hours||Thirty minutes following transfer back to his ward, Mr Plumb began complaining of severe abdominal pain, rotating to his back. He was given morphine. It was noted that he was having problems voiding urine.|
|1550 hours||Reviewed by Dr Jun How Low, a surgical intern. Pain was reported to be 6/10 despite the pain medication, and Mr Plumb had a tender abdomen. He was also unable to void his bladder.|
|1600 hours||Dr Low discussed concerns regarding Mr Plumb’s condition with Dr Anderson. Dr Anderson advised that he would review Mr Plumb later.|
|1630 hours||Dr Low noted that at the end of his shift, Mr Plumb’s pain and nausea were in control.|
|1840 hours||Reviewed by Dr Anderson. Dr Anderson inserted a catheter and drained 400mls of urine. Mr Plumb obviously distressed and still in pain. A CT scan was ordered.|
|1855 hours||Blood test was performed. This indicated an elevated lipase, high white blood cell count and high neutrophils. However, blood tests had not been taken prior to the surgery to compare these results against.|
|1950 hours||CT scan was performed.|
CT scan results ruled out pancreatitis and indicated that Mr Plumb’s common duct and/or had been perforated during the surgery.
Dr Anderson was advised via telephone of the results by radiologist, Dr Matar.
|2155 hours||Dr Anderson advised nursing staff to use conservative management of Mr Plumb’s condition. This included IV fluids, antibiotics, hourly urine output measures, and pain killers when necessary.|
Reviewed by Dr Gabruseva. Noting Mr Plumb’s condition, his blood tests and Mr Plumb’s CT results communicated to her by the nursing staff, she noted that “clinically perforation was highly likely”. She decided to continue with Dr Anderson’s management plan with antibiotic therapy and fluid boluses were escalated with use of stronger antibiotics.
Dr Gabruseva requested that the nursing staff inform Dr Anderson of Mr Plumb’s condition.
|0415 hours||Nursing staff contacted Dr Gabruseva to advise that Mr Plumb’s urinary output was only 10ml over an hour. She increased his albumin over the phone.|
|0440 hours||Reviewed by Dr Gabruseva. Mr Plumb showed no signs of improvement. His abdomen was rigid and tender. Not enough staff in the Critical Care Unit (‘CCU’) for Mr Plumb to be moved.|
|0530 hours||Reviewed by Dr Gabruseva. Mr Plumb’s condition was continuing to deteriorate. Dr Anderson was contacted. The decision was made that Mr Plumb be transferred to the CCU.|
|0615 hours||Dr Gabruseva contacted Dr Anderson to inform him of Mr Plumb’s deteriorating condition.|
|0630 hours||Dr Ian Walker-Brown, a locum medical officer in the CCU received a handover regarding Mr Plumb in anticipation of his arrival to the unit. Mr Plumb was described as peritonitic and hypotensive.|
|0700 hours||Mr Plumb arrived in the CCU and was reviewed by Dr Hermann Wittner. His blood tests showed renal failure and CT scan indicated a bile duct or duodenal perforation. Dr Walker-Brown placed a number of lines and started inotropic support, fluid resuscitation and fentanyl infusion for pain relief.|
|0925 hours||The decision was made that Mr Plumb be transferred to the Wesley Hospital for surgical management via Careflight.|
|Events at the Wesley Hospital|
Mr Plumb was taken to the operating theatre immediately upon arrival. Two-three litres of bile were found in the peritoneum, and a perforation at the junction of the common bile duct, pancreatic duct and duodenum were discovered. These were repaired, and the peritoneum was washed out.
Mr Plumb was returned to the ICU.
|No date||Mr Plumb was taken to the operating theatre on two further occasions to determine the cause of ongoing sepsis. Signs of progressive retroperitoneal and fat necrosis, duodenal defect and extensive adhesions were present.|
|17.10.14||The decision was made that Mr Plumb was not to have his treatment escalated, and that he was not to be resuscitated in the event of deterioration.|
|21.10.14||Active treatment was withdrawn, and palliative care was commenced.|
|23.10.14||Mr Plumb was pronounced deceased at 2340 hours.|
|Autopsy revealed that death was due to multiple organ failure, sepsis, perforation of the junction of the common bile duct, pancreatic duct and duodenum, elective endoscopic retrograde cholangiopancreatography (ERCP) and spincterotomy and biliary calculi.|