Death prompts call for hospital rethink

INEXPLICABLE doctor error and other failures at the Launceston General Hospital led to a woman who needed immediate heart surgery dying hours after being sent home, a coroner says.

Coroner Rod Chandler has recommended the hospital review the competency of its radiological staff.

He said Maureen Rogers, 71, was denied the opportunity of a full recovery as a result of the LGH failure to properly diagnose her condition.

Radiologist Anil Gupta missed obvious signs and failed to make complete observations that could have alerted other staff to the emergency, Mr Chandler reported. LGH medical staff diagnosed Ms Rogers with an intestinal complaint, despite symptoms possibly also pointing to a heart problem, sending her home nine hours after arriving in an ambulance, in November 2012.

Her son found her dead in bed the next morning after she suffered a heart attack.

Dr Gupta accepted his failure to recognise key signs on Ms Rogers’ heart scans, regretted his error and acknowledged the distress it had caused Mrs Rogers’ family and friends, Mr Chandler said.

Dr Michael Carr, director of medical imaging at the Royal Hobart Hospital, told the coroner’s inquiry the correct diagnosis “was obvious from the CT scan and should have been made by Dr Gupta”.

“The error made by Dr Gupta was inexplicable given that he was specifically requested by the clinician to exclude dissection of the aorta as the diagnosis,” Dr Carr said.

Mr Chandler said it was clear Ms Rogers presented suffering an aortic dissection requiring “immediate surgery”.

“The circumstances surrounding Mrs Rogers’ unfortunate death lead me to recommend that the LGH undertake a review of the competencies of its radiological staff with a view to putting in place, if deemed necessary, processes for their updated training and the proper supervision or monitoring of their work,” he said.