‘We need adequate staffing’: Broome doctor to coroner after tragic ‘misadventure’ death

A coronial investigation into the death of a Kimberley man, who suffered internal bleeding as a result of a “misadventure” during surgery, has slammed policy and procedure at Broome Hospital and called for clear leadership guidelines to be established. Fitzroy Crossing man Mr Churchill went to Fitzroy Hospital on October 26, 2017 complaining of pain in the right upper quadrant of his body, with a portable ultrasound later finding he had gallstones and a dilated gallbladder. He was transferred to Broome Hospital on October 27, 2017. After undergoing tests, Mr Churchill was reviewed by Dr Saranga Ranasinghe, a general surgeon at the hospital, and another colleague. Dr Ranasinghe had 18 years experience, but when he reviewed Mr Churchill, he had only been employed at the hospital for five days as a locum. He decided to remove Mr Churchill’s gallbladder to prevent any septic related complications. During the procedure, district medical officer and anaesthetist Dr Kevin Ng mentioned that the gallbladder bed appeared “oozy” — that there appeared to be some bleeding. He also showed concern at the end of the procedure that the fluid coming from Mr Churchill was not “very clear”. Dr Ranasinghe assured Dr Ng this was not a cause for concern. After the procedure was completed at about 2.16 pm, Mr Churchill was “woken up” by Dr Ng and taken to the recovery area at about 2.20pm. Dr Ng satisfied himself that Mr Churchill’s observations were stable and did a verbal handover to the nurse in the recovery area. About 10 minutes later Dr Ng was called back to the recovery area by nursing staff who were concerned that Mr Churchill’s blood pressure had dropped. A temporary improvement to Mr Churchill’s blood pressure was noted following treatment. Dr Ng noted that Mr Churchill’s abdomen was distended. Given his poor response to blood pressure medications, Dr Ng was concerned that the most likely cause of Mr Churchill’s hypotension was intra-abdominal bleeding. Dr Ng then asked Dr Ranasinghe to urgently review Mr Churchill. However, Dr Ranasinghe felt that the cause of Mr Churchill’s symptoms was more likely to be a septic event during surgery. “Mr Churchill’s temperature was normal, he was not experiencing chills or rigors and he had normal feeling and pulses in his peripheries. For those reasons, Dr Ng concluded that Mr Churchill was not septic and instead, that blood loss was the most likely cause of his unstable condition,” the report said. Even though both intra-abdominal bleeding and a septic event were being considered as causes for Mr Churchill’s symptoms, a majority of the treating team were influenced by Dr Ranasinghe’s view that a septic event was the more likely explanation. As it turned out, Dr Ng’s assessment was entirely correct. Mr Churchill was returned to the operating theatre at about 5.25pm. Although Mr Churchill’s blood pressure was dangerously low at the start of the second procedure, Dr Ranasinghe was able to locate and repair the source of the bleeding; a defect in an aberrant branch of the cystic artery. About three litres of blood was drained from Mr Churchill’s abdomen during this second procedure, which was completed at about 7pm. In the recovery area, Mr Churchill was in a “critical but stable condition”. As a result of this complication, it was decided to transfer Mr Churchill to Royal Darwin Hospital. Mr Churchill arrived at RDH via the Royal Flying Doctor Service on the morning of October 28, 2017. He had no signs of ongoing bleeding and was diagnosed with multiple organ dysfunction syndrome. He was admitted to the intensive care unit where he was treated for MODS and renal failure. Mr Churchill’s medical condition did not improve. Following discussions between his family and his treating team it was decided to treat him palliatively. His family arrived in Darwin on November 12, 2017 and it was agreed that he be transferred to the RDH hospice. Initially, he was responsive at times but his condition deteriorated and he died at the RDH hospice at 1.05 pm on November 13, 2017. Coroner Michael Jenkin said the autopsy found Mr Churchill’s cause of death was “surgical complications” following the gall bladder surgery. “Further, given that Mr Churchill’s internal bleeding was caused by the inadvertent cutting of an aberrant branch of his cystic artery during a surgical procedure, I find that death occurred by misadventure,” he said. Five recommendations were handed down by the coroner. This included calling for proper training and standards for use of ultrasound equipment, amendments to the WA Country Health Service’s health records management policy, training to improve communication between clinicians involved in patient care and a clearer identification of the team leader in emergency situations. In the conclusion of his investigation, Mr Jenkin said the clinicians involved should have identified the issue earlier. “(Mr Churchill) underwent a procedure to remove his inflamed gallbladder and thereafter, he developed dangerously low blood pressure. Two causes for his unstable condition were considered, namely sepsis and blood loss,” he said. “Unfortunately, it took some time for Mr Churchill’s treating team to conclude that blood loss was more likely and therefore, that the risk of returning him to the operating theatre to address this issue was justified. “On the basis of the available evidence, I concluded that Mr Churchill’s treating team should have identified blood loss as the more probable explanation for his unstable condition at an earlier point than they did. “I have also referred to issues of communication and leadership during medical emergency calls and as a result of my observations, I have made five recommendations, which I hope will be embraced.” Questions of appropriate staff levels at Broome Hospital were raised during the inquest, with Kimberley district medical officer Dr Saharov highlighting it as a key issue facing the facility. “The last point I want to make, we need adequate staffing,” he said. “We’re desperately short of everyone in the Kimberley, but ... Broome Hospital is becoming busier. As the region gets more and more stressed with lack of staff, because of borders ... and more workers coming to Broome Hospital, we’re busier than ever. “Our staffing has not increased proportionally, it has gone backwards and as a result, we have more and more (indistinct) overload. We don’t have the capacity to respond to emergencies with a ... cognitive capacity that we need both, let alone physical capacity.” In response to the comment on staffing levels, Mr Jenkin said while the evidence showed additional staff would not have had an impact on Mr Churchill’s outcome, staffing pressures were relevant to this death in another way — the use of locum staff. “In general terms, I am not critical of the use of locum staff by BH, in the sense that locum staff are better than no staff at all. However, I am concerned about the implications of relying on locum staff as opposed to recruiting and retaining staff that reside in the local area on a permanent basis.” “In this case, Dr Ranasinghe was a locum and had only been at the hospital for five days when he became involved in Mr Churchill’s care. His status as a locum surgeon did create issues. First in terms of his familiarity with local procedures and second in terms of the rapport he had been able to develop with other staff. “Dr Saharov gave evidence that he was unwilling to challenge Dr Ranasinghe’s clinical opinion on the basis that they had not developed a working relationship.” Mr Jenkins said it would be preferable for the use of locum staff at Broome Hospital to be kept to a minimum, and for staffing levels to be reviewed. A plethora of cases involving deaths at WA hospitals saw Australasian College for Emergency Medicine WA chairman Dr Peter Allely recently warn of “catastrophic” problems in the State health system. Mr Allely said doctors were “not providing first world care to patients” because there was no space in WA’s hospitals, likening emergency departments to refugee camps. Shadow health minister Libby Mettam said demands on WA hospitals had grown exponentially in the past 12 months, despite next to no community spread of COVID-19, no flu season and reduced levels of elective surgery. “The McGowan Government is not resourcing our hospitals at the levels required ... it is only a matter of time until patients are harmed,” Ms Mettam said.