Hospital 'missed opportunity' before patient's death

A CORONER has concluded earlier transfer of a deteriorating post-surgery patient in Bundaberg "would likely have improved" his chances of survival.

Deputy state coroner John Lock said a CT scan revealing Mark Anthony Plumb, 76, had a suspected perforation should have been a "game changer" in the way his complications were treated after gallstone removal surgery.

He said there were multiple missed opportunities to escalate his case before he was transferred from Friendly Society Private Hospital at Bundaberg to Wesley Hospital in Brisbane.

Mr Plumb's wife Joyce and other family members, who had voiced concerns about the medical care at the hospital, travelled from Agnes Water to hear the findings delivered in Brisbane Coroners Court on Friday.

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They told ARM Newsdesk outside court that the findings were what they had expected and they hoped new procedures in place at the hospital meant this would not happen to anyone else.

Mr Plumb had surgery on September 19, 2014, and began experiencing severe abdominal pain soon after the procedure.

A CT scan revealed a suspected perforation of his duodenum or common bile duct, with free fluid in his abdomen.

He died on October 23 after failing to improve from further procedures at Wesley.

Mr Lock said the perforation risk during such a surgery was 1-1.3%, with a mortality rate of 18% if a perforation occurred.

He said the surgeon, Dr Pitre Anderson, maintained a conservative treatment plan for the pain even after the CT scan.

"There was no escalation of treatment despite Mr Plumb's deterioration being noted for over 11-16 hours during which time Mr Plumb became septic," Mr Lock said.

"By the time of transfer to Wesley Hospital in Brisbane, and despite maximal treatment being provided to him, Mr Plumb had a poor prognosis and subsequently died.

"An earlier recognition of deterioration and transfer for appropriate care would likely have improved Mr Plumb's chances of survival from his perforation."

Mr Lock said Dr Anderson had since retired and was unwell. He said he did not intend to make a referral to a disciplinary body as a result.

But he said independent expert Dr Phil Lockie did have concerns about Mr Plumb's post-operative care and believed Mr Plumb should have been transferred to Brisbane hours earlier than he was.

"The main missed opportunity was in Dr Anderson not reviewing Mr Plumb after the CT scan or at least flagging to nursing and medical staff the need to be vigilant in monitoring Mr Plumb for deterioration consistent with the effects of a perforation," he said.

"That may have resulted in an escalation of action many hours earlier, before Mr Plumb's serious deterioration set in.

"It is unclear if earlier intervention as provided by Wesley Hospital would have made a difference to the outcome for Mr Plumb but at a commonsense practical level the earlier attention is given the better the prospects must be."

No further recommendations were made, given the hospital no longer performed such procedures and had implemented a number of changes since Mr Plumb's death.

"A number of improvements have been made regarding assisting nursing staff in recognising a deteriorating patient, improving communication and the management of pain at the hospital," Mr Lock said.

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