Inquest into death of Sandra McRae [2008] NTMC 64 (29 October 2008)
CITATION: Inquest into the death of Sandra McRae [2008] NTMC 064TITLE OF COURT: Coroner’s Court
JURISDICTION: Darwin
FILE NO(s): D0038/2005
DELIVERED ON: 29 October 2008
DELIVERED AT: Darwin
HEARING DATE(s): 16 – 18 July 2008
FINDING OF: Mr Greg Cavanagh SM
CATCHWORDS: Unexpected Hospital Death, Pulmonary Embolism as a consequence of Fractures, Care and Treatment Thereof.
REPRESENTATION:
Counsel:
Assisting: Jodi Truman
Department of Health: Kelvin Currie
Judgment category classification: B
Judgement ID number: [2008] NTMC 064
Number of paragraphs: 129
Number of pages: 33
IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN
TERRITORY OF AUSTRALIA
No. D0038/2005
In the matter of an Inquest into the death of
SANDRA MCRAE
ON 13 MARCH 2005
AT THE INTENSIVE CARE UNIT,
ROYAL DARWIN HOSPITAL
FINDINGS
29 October 2008
Introduction
1. Sandra McRae (“the deceased”) was a Caucasian female born on 5 May 1947 in Bradford upon Avon in the United Kingdom. At approximately 10pm on 25 February 2005 Mrs McRae was involved in a motor vehicle accident at the traffic light intersection of the Stuart Highway with Deviney Road. As a result of that accident she was hospitalised. Shortly following her admission, the deceased was placed under the care of the orthopaedic unit at RDH as she had suffered several fractures. Several days post her admission, on 12 March 2005, Mrs McRae collapsed and suffered a cardiac arrest and was found to have suffered a pulmonary embolism. Mrs McRae died from the pulmonary embolism at approximately 10.45am on 13 March 2005 in the Intensive Care Unit (ICU) at the Royal Darwin Hospital (RDH). A pulmonary embolism is a not unexpected consequence of the injuries suffered by the deceased, and there are ‘thromboprophylactic’ treatments available which are given to reduce the chances of such a death.
2. Ms Jodi Truman appeared Counsel assisting on each day of this inquest from 16 to 18 July 2008. I thank her for her valuable assistance. Mr Kelvin Currie appeared as Counsel for the Department of Health and Family Services.
Formal Findings
3. Pursuant to section 34 of the Coroners Act (“the Act”), I find, as a result of evidence adduced at the public inquest as follows:
i. The identity of the deceased person was Sandra McRae, born on 5 May 1947. The deceased resided at 9 Dowdy Street, Millner in the Northern Territory of Australia.
ii. The time and place of death was in the ICU at RDH at 10.45am on 13 March 2005.
iii. The cause of death was acute pulmonary embolism.
iv. Particulars required to register the death:
a. The deceased was female.
b. The deceased’s name was Sandra McRae.
c. The deceased was of Caucasian descent. The cause of death was reported to the Coroner.
d. The cause of death was confirmed by post mortem examination carried out by Dr Terry Sinton.
e. The deceased lived at 9 Dowdy Street, Millner in the Northern Territory.
f. The deceased was retired.
g. The deceased was married to Kevan James McRae.
4. Before setting out my findings upon this Inquest, I note that section 34(2) provides that I may comment on a matter including public health or safety connected with the death being investigated. Additionally, I may make recommendations pursuant to section 35 as follows:
“(1) A Coroner may report to the Attorney General on a death or disaster by the Coroner.
(2) A Coroner may make recommendations to the Attorney General on a matter, including public health or safety or the administration of justice connected with a death or disaster investigated by the Coroner.
(3) A Coroner shall report to the Commissioner of Police and Director of Public Prosecutions appointed under the Director of Public Prosecutions Act if the Coroner believes that a crime may have been committed in connection with a death or disaster investigated by the Coroner”
This is an important section in the context of this Inquest.
The Conduct of the Inquest
5. Sergeant Anne Lade, following the outcome of a criminal trial in relation to the motor vehicle accident, investigated this death. I have before me a Coronial Brief in relation to the investigation compiled by Sergeant Lade (Exhibit 1). I also have 6 additional exhibits as follows:
i. RDH file for Sandra McRae.
ii. Documents provided to Sgt Lade from RDH.
iii. Copy of passport for Sandra McRae.
iv. Diagram of pelvis as marked by Mr Mehta.
v. Medical certificate for Mr Cripps dated 17 July 2008.
vi. Victorian Council Consultative Report and article of Sharrock et al.
6. I heard oral evidence from Sergeant Anne Lade and Mr Kevan McRae. I would like to thank Mr McRae for his evidence and to commend him for the respect he has shown to the process and the assistance he provided to this court.
7. I also received oral evidence from 3 consultants who were part of the orthopaedic unit at RDH at the time of Mrs McRae’s death, and who remain so now; Mr Janak Mehta, Mr Matthew Sharland and Mr Robin Cripps. I also heard from Dr Dianne Stephens, called by the Department of Health and Community Services, on behalf of RDH. Dr Stephens is the Director of the Intensive Care Unit and Medical Coordinator of the Division of Surgery and Critical Care at RDH.
8. Finally I heard oral evidence from Professor John Hart who was accepted by all persons, and this court, as an expert in the field of orthopaedics. Professor Hart’s qualifications are attached to his report, which forms part of exhibit 1. Professor Hart’s evidence was extremely helpful to this inquest.
Circumstances surrounding the death
Events leading up to hospitalisation
9. At the time of her death Sandra McRae was 57 years of age. After working her whole adult life she retired on the same day as her husband on 17 September 2004. Their plan was to go on a “trip of a lifetime” around Australia together. The couple were in the final stages of preparations and arrangements for that trip. I heard evidence from Mr McRae that he and the deceased had changed their exercise regime to “get fit” for their trip, as it was intended that their trip would involve bush walking and the like. They had made also changes to their house for their departure. It is clear that they were both very much looking forward to their trip together.
10. On 25 February 2005 at about 10pm, the deceased was driving her motor vehicle; a red Corolla Hatchback. She was alone in that car when she was struck by another motor vehicle at the traffic light intersection of the Stuart Highway with Deviney Road. The person that caused that motor vehicle accident was Mr Darren John Partridge.
11. At about 9.30pm on the evening of 25 February 2005 Darren John Partridge was at unit 2/86 Dwyer Circuit in Driver. Police were dispatched to attend a disturbance at that address. When they attended they found Mr Partridge sitting in the driver’s seat of his vehicle. The car was parked in the driveway and Mr Partridge had the keys in his possession, but the engine was not running.
12. The police spoke with Mr Partridge and noticed that his speech was slurred, he kept repeating himself, his eyes were blood shot and he smelt of alcohol. Upon the request of the police Mr Partridge gave his keys to the police officers, who then gave them to the occupant of unit 2 for safekeeping. Police told Mr Partridge not to drive his car. Mr Partridge got out of the vehicle and went into the unit, saying to police that he was going to go to sleep. Police noted at that time that Mr Partridge was unsteady on his feet.
13. Unfortunately, shortly after the police left, Mr Partridge came into possession of his keys and he drove away from unit 2. The facts that were admitted by Mr Partridge before the Supreme Court were that Mr Partridge drove his vehicle along Roystonea Avenue towards the intersection with the Stuart Highway. As he approached the intersection he was facing a red traffic light. He failed to stop at that red traffic light. He proceeded through the intersection; turning left onto the Stuart Highway, and then drove inbound along the Stuart Highway, travelling in excess of the clearly marked 80km speed limit.
14. As he approached the intersection with Deviney Road, the traffic lights facing him were red. The orange warning lights, situated some 140m from the intersection, were also flashing. There was one vehicle located in each of the inbound lanes. Both of those vehicles were stationary at the red light. One of those vehicles was the red Corolla Hatch Back occupied by and belonging to the deceased, which was in the left lane. The other vehicle was a silver Daewoo Sedan, which was in the right lane.
15. Darren John Partridge continued to approach the intersection travelling in the left lane. He did not commence braking until he had almost reached the intersection. As Darren Partridge commenced braking, almost at the intersection, his vehicle swerved from left to right and struck both the red Corolla and the silver Daewoo. Mrs McRae’s vehicle took the brunt of the impact and sustained extensive damage to the rear right hand side and the rear right passenger door.
16. The vehicle occupied by Darren Partridge drove through the intersection and stopped in the left lane. He was subsequently taken to the RDH and a sample of his blood was taken at 11.09pm, some 1 hour after the accident. That sample returned a blood alcohol reading of 0.22.
17. St John Ambulance attended the scene and transported Mrs McRae to the RDH. The Ambulance report described the deceased as a little confused, with severe pain in the region of her left hip. She had normal blood pressure and heart rate, which meant she was haemodynamically stable at that time.
Events shortly after Hospitalisation
18. Mrs McRae was admitted to the emergency department at the RDH at 11.07pm. Her blood pressure and heart rate remained normal. She remained a little confused, but this is recorded as resolving over the next 3 hours. Her only complaint remained the pain in the left pelvic region and a small bruise was noted in that area.
19. Plain x-rays were performed on her pelvis. There was a “working diagnosis” that she had a fractured pelvis. X-rays were also taken of her neck to exclude a neck injury.
20. At the emergency department, the surgical registrar, Dr Jamieson, and the orthopaedic registrar, Dr Salaria, saw Mrs McRae and examined her x-rays. The x-rays of her neck were normal, and the pelvic x-ray showed fractures of the right superior and inferior pubic rami and the left superior pubic ramus. During this inquest I had tendered before me a diagram (exhibit 5) depicting precisely where these fractures occurred.
21. Thereafter Mrs McRae was admitted to Ward 3A, which is the orthopaedic ward. A plan was put in place for bed rest. Mrs McRae was placed upon a Jordan frame, which is a frame placed under a patient and allows only minimal patient movement; designed to keep a patient immobile.
22. Although not actually seen by him at the time of her admission, the bed card for Mrs McRae recorded Mr Cripps as her consultant. She was therefore, according to the RDH records, noted as being under his care.
23. At 2.40am on 26 February 2005 it is noted that Mrs McRae was admitted to Ward 3A under the care of Mr Cripps, who was at that time a senior orthopaedic surgeon and consultant and to whom Dr Salaria was the orthopaedic registrar. There is no evidence in the notes, or before me, to suggest however that Mrs McRae was actually seen by Dr Cripps at that time. The RDH records set out the diagnosis, management plan and complaints for each day that Mrs McRae was a patient at the RDH. It is clear from the evidence that Mr Mehta, Mr Sharland and Mr Cripps were each involved at various stages in the care of Mrs McRae.
Events during the hospitalisation
24. I heard evidence from Mr Mehta that as an employee and consultant at RDH, he and the other consultants were placed on rosters in terms of their duties at the hospital. Part of exhibit 3 includes rosters for the period during which the deceased was admitted to the RDH. I also heard from Mr Mehta that there could be changes to that roster, however if changes were to occur, notice was to be given to the surgical coordinator so that amendments could be made to the written roster to properly reflect those on duty at the relevant time.
25. Reflecting that evidence are the rosters in exhibit 3, which show that a number of amendments occurred to some of those rosters. Those amendments are reflected on the roster record itself, at the top right hand corner, which also records how many amendments have occurred to the roster.
26. I note that for the purpose of the inquest, Mrs McRae arrived at the emergency department at 11.04pm on the evening of 25 February 2005. The orthopaedic roster states that the specialist on duty on 25 February 2005 was Mr Cripps. Mr Cripps is recorded in the roster as being the specialist on duty up to and including 27 February 2005.
27. In evidence before me Mr Cripps initially stated that he could not recall where he was during the period in which Mrs McRae was admitted to hospital, ie. 25 February 2005 until 13 March 2005. Mr Cripps stated that he was on leave but he assumes that he was at home. Mr Cripps stated that he had a “clear memory” of being on 2 weeks annual leave during that time.
28. Mr Cripps then subsequently gave evidence that he “specifically” recalled being on annual leave as and from Monday 28 February 2005 for 2 weeks. Mr Cripps gave evidence that he returned to work on 7 March 2005. Unfortunately the hospital records do not reflect that leave having ever been approved within their own records, nor has there been a corresponding amendment to the orthopaedic roster reflecting that change for the relevant periods. I will return to this aspect of the evidence later.
29. Despite this, and for whatever reason, Mr Cripps is not recorded in the hospital records as having seen Mrs McRae until 7 March 2005. For the purpose of this inquest I have recorded Mrs McRae’s late night attendance at the hospital on 25 February 2005 as day 1. I note this is also how Professor Hart has recorded the days in hospital. The first recording of Mr Cripps seeing Mrs McRae is 7 March 2005, which was day 11 of her admission to the hospital.
30. It appears from the RDH records that the first time that Mrs McRae was attended upon by a senior orthopaedic Surgeon was when she was seen by Mr Mehta on 28 February 2005, being day 4 of her admission.
31. The orthopaedic department is headed by a Director. The position was held at the time, and is still held, by Mr Matthew Sharland. There were, as at February 2005, 3 teams within the orthopaedic division, each headed by a consultant, namely Mr Sharland, Mr Cripps and Mr Mehta. Within each of those teams, under the supervision of the consultants, was a registrar and then a registered medical officer or intern.
32. I heard evidence in relation to Mr Mehta that as at February 2005 he had not yet achieved his qualifications in terms of an Australian Fellowship. Mr Mehta was therefore at that time trained overseas as an orthopaedic specialist and was undergoing supervised practice in Australia. As a result Mr Mehta was required to be supervised by Mr Sharland. It appears however that Mr Mehta was considered by Mr Sharland and Mr Cripps to be more than capable and appears therefore that very little actual supervision occurred in relation to Mr Mehta by any other consultant.
33. Mr Mehta gave evidence that whenever a consultant was away, one of the other consultants would take over management of that consultant’s patients. Mr Mehta stated that in terms of taking over the management of care of that patient there would be a “formal handover”. That formal handover he described as being verbal and usually via the absent consultant’s registrar. As at February 2005 the orthopaedic team headed by Mr Cripps had Dr Alex Blythe and Dr Othman Hamid as its registrars.
34. I heard evidence that in terms of decision-making, the final decision rested with the consultant on each team. Mr Mehta also gave evidence that if he had confidence in a registrar he would anticipate that the registrar might make decisions in relation to the treatment to be provided to a patient, without discussing the treatment plan with him before its commencement. Mr Mehta did note however that he “micro managed” his teams, including when he temporarily took care of a team whilst another consultant was away, and therefore was heavily involved in the decisions to be made as to appropriate treatment for a patient.
35. In considering this evidence from Mr Mehta, I also have in evidence before me the evidence given by Dr Blythe at the criminal trial. The transcript of that evidence states at page 53, at about point 5, that it was the consultant specialists who made the final decision as to whether thromboprophylactic treatment should be commenced in relation to the treatment of Mrs McRae.
36. In relation to the decision as to whether to commence thromboprophylactic treatment or anticoagulant therapy, Dr Blythe is recorded in the transcript at page 62, at about point 1, as follows:
“I have to restate my position that this was a clinical decision and that yes, she was at a risk of deep vein thrombosis and she was at a risk of pulmonary emboli. When she first arrived at hospital she was at risk of bleeding to death and a clinical decision was made on an ongoing basis from the day of her admission until the day she died as to whether DVT prophylaxis was appropriate or not and in such difficult circumstances a clinical decision is required, I speak to my senior doctors which I did and the consensus decision was that she did not need DVT prophylaxis”.
37. Although I note that such evidence suggests that the decision surrounding the use of thromboprophylactic treatment was considered every day of the deceased’s admission, that was not the evidence before me, and I do not accept that part of the evidence. However the remainder of the evidence is important in terms of who was responsible for making such a decision.
38. It is also clear from the evidence given by Mr Mehta that it was he who made a decision on 28 February 2005 (when he first attended upon Mrs McRae) in relation to the use of thromboprophylactic treatment. Mr Mehta states his decision was not to commence such treatment. I will return to this part of his evidence later. Mr Mehta openly and frankly conceded that in terms of decision making for patients, the responsibility rested with the consultants. In my opinion that was an obvious, yet appropriate, admission to make.
39. I heard evidence that as at on 25 February 2005, and continuing thereafter, Mrs McRae was recorded as being haemodynamically stable. Mr Mehta gave evidence that as at 28 February 2005 he considered the pelvic fracture sustained by Mrs McRae to also be stable. I note that Mr Cripps gave evidence to this effect as well.
40. Mr Mehta also gave evidence however that he was concerned about the possibility of damage to the sacrum, which appears as a large triangular bone at the base of the spine and at the upper and back part of the pelvic cavity, inserted like a wedge between the two hip bones. As a result of that concern Mr Mehta gave evidence that he sought on 28 February 2005 for a CT scan that had been previously ordered to be “chased” up.