January 31, 2018
The treatment of a 48-year-old man who died of a heart attack and pneumonia at Cherbourg Hospital in 2016 was full of “missed opportunities”, an inquest into his death has found.
However, Acting Coroner Ainslie Kirkegaard said she found no reason to refer any of the clinicians involved in the care of Roy Rodney Jacobs to the Health Ombudsman.
Mr Jacobs died in the early hours of August 31, 2016.
He had travelled from Brisbane to Cherbourg on August 26, 2016, to attend a funeral. He drank alcohol at a gathering and had a fall while intoxicated.
Mr Jacobs attended Cherbourg Hospital three times after the fall – on August 28, 29 and 30 – and was admitted to hospital on the final occasion for treatment.
An independent review of Mr Jacobs’ treatment at the hospital found that he was treated reasonably or acceptably on the first two occasions.
However, on the third occasion it was inappropriate.
“The management of Roy’s third presentation on August 30 was inappropriate as notwithstanding his markedly abnormal vital signs, there was no apparent consideration of alternative diagnoses or discussion with either a referral centre such as Toowoomba Base Hospital or an experienced critical care physician,” Dr Greg Treston, Director of Emergency Medicine at the Mater Misericordiae Hospital, said.
The clinical review team also expressed concern that potentially there was a focus on perceived intoxication/alcohol withdrawal rather than the deteriorating patient and/or co-existing conditions.
The Acting Coroner noted that since Mr Jacobs’ death in 2016, concerted efforts had been made at Cherbourg Hospital to ensure nursing staff understood and complied with policies and procedures for reviewing, recording and actioning patient vital signs and other observations, and for escalating clinical concerns.
In 2017, Cherbourg Hospital began using the Telehealth Emergency Management Support Unit (TEMSU), as a Brisbane-based service providing advice to rural nurses when assessing/triaging patients or when on the ward before contacting an on-call medical officer.
“I am in no way suggesting the issues examined by this inquest are specific to Cherbourg Hospital or the DDHHS alone,” Acting Coroner Kirkegaard said.
“Failure to recognise and respond to clinical deterioration and non-compliance with early warning and response tools is a recognised issue across the health sector, public and private.”
However, she said the inquest had identified multiple missed opportunities to have optimised Mr Jacobs’ care with further medical review and reassessment.
“While I accept those opportunities, if taken, may not have prevented Roy’s death, I do consider they were significant in maximising the potential for a different outcome for him,” she said.
“While aspects of his care were suboptimal, no one individual was responsible for these failings; rather a cascading sequence of events led up to his sudden and unexpected death.
“As such I do not consider the circumstances in which Roy died warrant referral of any of the clinicians involved in his care to the Health Ombudsman.”
The inquest into Mr Jacobs’ death was held in Brisbane late last year.
