Coroner concludes delayed diagnosis did not contribute to unexpected death

This coroner’s case highlights the complexities of managing a patient with a complex medical history and the challenges this brings in making a timely diagnosis.  As is evident in this case, diagnosis is often an evolving process, and symptoms may need to persist or worsen before a diagnosis can be made.  In some instances, such as this one, time itself serves as a diagnostic tool.

While the care was ultimately found to have been appropriate, the delayed diagnosis underscores the importance of vigilant monitoring to minimise diagnostic delays.

Mr B had a complex medical history including increased BMI, kidney cancer, ischaemic heart disease, hypertension, high cholesterol and gastro-oesophageal reflux disease. He had previously undergone prostate surgery and gastric band surgery.

He was experiencing reflux that could not be controlled medically and had continued to gain weight despite the gastric band. Eventually a hiatus hernia was detected. Having considered multiple treatment options he decided to explore gastric bypass surgery. A multi-disciplinary team assessed him as fit. 

Dr Z conducted the technically-difficult surgery involving division of extensive adhesions, removal of the previous gastric banding, repair of the hiatus hernia and a gastric bypass procedure. The surgery was completed successfully.

Post-surgery, Mr B received routine antibiotics and deep vein thrombosis (DVT) prophylaxis including twice daily subcutaneous heparin injections, compression stockings and pneumatic calf compressors. He was administered morphine via a patient-controlled analgesia device.

Over the following days, Mr B complained of increased abdominal pain, however his vitals were normal. Scans suggested a new epigastric hernia and possible small bowel perforation.

Dr Z conducted a laparoscopy and found the bowel was intact with no perforation or obstruction. All components of the bypass surgery were also intact. Dr Z repaired the hernia and Mr B was commenced on intravenous antibiotics. 

Mr B initially appeared to be recovering, but then reported feeling unwell, with shivering, sweating and nausea Over the course of the next few days he experienced inconclusive symptoms including an episode of tachypnoea, feeling unwell and faint. 

In the early hours of the morning, the medical emergency team (MET) was called. The intensive care unit (ICU) registrar attended and examined Mr B. Follow-up and tests were ordered but results were not yet available when Mr B suffered a cardiac arrest. 

He was revived and transferred to ICU but experienced repeated arrests leading to multiple organ failure, hypoxic brain injury and ultimately to his death.

The cause of death was determined as pulmonary thromboemboli in the context of recent surgery. 

The case was referred to the coroner.

Standard of care – missed or delayed diagnosis

Based on expert evidence, the coroner accepted that pulmonary embolism was a known but relatively low risk. Further, the risk had been managed appropriately and according to the applicable guidelines.

The coroner accepted that earlier administration of a therapeutic dose of anticoagulants may have prevented Mr B’s death. However she noted the risk of hindsight bias in such cases. Based on Mr B’s presentation and what was known at the time, she concluded that Mr B’s care had been appropriate.

The registrar responding to the MET call had conducted a thorough examination and recorded differential diagnoses of sepsis, a possible cardiac event or pulmonary embolism. The coroner accepted evidence that it was reasonable to consider pulmonary embolism as the least likely diagnosis and to first act to rule out other causes.

It would have been possible to order a CT pulmonary angiogram (CTPA), but this was not standard practice and on the weekend it would have taken some hours to arrange.

The coroner concluded that even if, during the morning, there may have been sufficient grounds to suspect and diagnose a pulmonary embolism and begin administering therapeutic doses of anticoagulants, this would not have been in time to change the outcome for Mr B.

Documentation

The coroner was particularly complimentary of Dr E, the ICU registrar who attended the MET call. The coroner found they had conducted a very thorough examination, had undertaken appropriate investigations, and clearly documented their findings, differential diagnoses and management plan. Their handover of care was ‘entirely appropriate and above reproach’.

The coroner found that concerns about possible bleeding were never noted in the medical records, and accepted these should have been recorded as they may have assisted other nursing and medical staff. However she accepted that the follow-up indicated that Mr B’s doctors were considering this possibility and ultimately she made no criticism of this omission.

The coroner did note that the case serves as a reminder of the importance of accurate documentation in medical records. These should adequately outline the doctor’s thoughts and plans so that there is no doubt in the minds of those taking over care as to what was to occur in future.

Ultimately the coroner concluded Mr B’s death was not preventable and that his doctors’ care had been reasonable and appropriate.

Arriving at a correct and timely diagnosis can be challenging, especially for patients with complex medical histories. In such situations, it is important to use all available resources to aid in decision-making and keep an open mind as to possible causes.

If a delayed diagnosis is referred to a coroner, it does not necessarily imply that the care provided was inappropriate. These reviews can serve as a valuable learning tool.

Carefully documented clinical notes are essential. Comprehensive documentation is critical in addressing the risk of hindsight bias by clearly reinforcing what is known and understood at the time clinical care decisions are made.

Avant video – Preparing a statement for the coroner

For medico-legal advice, please contact us here, or call 1800 128 268, 24/7 in emergencies.