Hospital care ‘substandard’

Former butcher’s death result of delays in treatment

A DEVONPORT man in his 70s died following substandard medical practice in Tasmania’s hospital system, a coroner has found.

Terence John Carroll, 71, died on June 8, 2019 from complications arising out of a perforation in his oesophagus caused from a dilation procedure at the North West Regional Hospital.

It occurred after the results from a CT scan from the Mersey Community Hospital were not communicated to his surgeon.

There were also delays in diagnosing the perforation at the Mersey emergency department after it occurred, causing delays in Mr Carroll receiving appropriate treatment.

In his findings published Friday, Coroner Robert Webster said the former butcher had been living at a nursing home when he was referred to the Mersey hospital – with a CT scan showing problems with his oesophagus and a radiologist advising an endoscopy to rule out malignancy.

An ear, throat and nose specialist conducted a procedure at the NWRH to check for abnormalities in, and to dilate, his oesophagus.

But when Mr Carroll’s family came to pick him up from hospital, they saw him “curled up on a bed, still in his gown” – and despite their concerns, were told he could not stay overnight after day surgery “because no beds were available”.

Mr Carroll went home only briefly before he was conveyed to the Mersey’s emergency department by ambulance that night.

The following day, scans taken at the hospital showed he had an oesophageal tumour with an oesophageal rupture and a collapsed left lung.

Mr Carroll was transferred to the Launceston General Hospital, undergoing surgery that night, and then transferred to the intensive-care unit.

He continued to undergo interventions over the coming days, but his condition worsened until the decision was made to treat him in palliative care back at the Mersey hospital, where he died a few months later. A Tasmanian Health Service panel determined the dilation procedure – which should be avoided or performed carefully in the case of a potentially malignant mass – was conducted “blindly” when the rupture occurred.

The panel also found due to Mr Carroll’s “impaired cognition, self-neglect and general frailty”, he should have been kept in hospital overnight.

Mr Webster said medical care from the time Mr Carroll reached the Launceston General Hospital – and the surgeon’s treatment at NWRH – was of a good standard.

“It was substandard medical practice, in my view, for the CT results not to be communicated to (the surgeon) and the delay in the diagnosis of the oesophageal perforation at the Mersey Community Hospital was also substandard because that delay then resulted in a delay in the provision of appropriate therapy,” he said.

Mr Webster said he was aware improvements had since been made within the Tasmania Health Service that would make a similar outcome in the future “far less likely”.