Post-op changes sought after death
Coroner acknowledges hospital has since implemented changes
A CORONER has recommended pre and post-operation procedural changes at Toowoomba Hospital after examining the circumstances surrounding the death of an Oakey woman who had surgery there.
Gwendoline Mead died on March 1, 2015, 12 days after having elective surgery to treat synchronous bowel tumours.
She had been formally diagnosed with high-grade rectal cancer in September 2014.
The inquest conducted by coroner Ainslie Kirkegaard identified a number of missed opportunities which could have optimised Mrs Mead’s care.
“While I cannot say with certainty those opportunities would have been outcome changing for Mrs Mead, I do consider they were significant in maximising the potential for better clinical outcomes,” she said.
Ms Kirkegaard cited improved pre-operative communication between medical teams as one such area of concern.
“The most significant of the missed opportunities flows from (Mrs Mead’s treating doctor) Dr Benny’s team not being involved in her management during the second November 2014 admission (to hospital).
“His involvement in investigating and managing her bowel complications at this stage of her neoadjuvant treatment would have better positioned him to reassess the planned surgical approach in light of those complications.
“Unfortunately there is insufficient evidence to identify exactly how this situation arose and whether it represents a broader system failure at Toowoomba Hospital.
“However, it arose in the context of a patient whose treatment plan had already been decided by a multidisciplinary team supported by Cancer Care Coordinators.
“The fact his team was not allocated to the surgical review requested by the medical oncology team suggests to me the need for Darling Downs Hospital and Health Service (DDHHS) to review the Surgical Oncology Multidisciplinary Team (SOMDT) mechanism to ensure the correct treating team is allocated to and/or notified at the time their patient requires investigation and treatment of complications emerging during and after the neoadjuvant therapy phase and prior to surgery.
“I recommend that DDHHS examine these aspects of its SOMDT model and formally report the outcomes of its review.
“Notwithstanding potential improvements to the SOMDT model to enhance surgical team awareness of emerging pre-operative issues, it remains incumbent on senior and junior members of all teams involved in a cancer patient’s pre-operative and post-operative care to actively read the patient’s chart.
“There were numerous instances of less than optimal or absent clinical documentation over the course of Mrs Mead’s final hospital admission.”
The Coroner acknowledge procedural changes had since been made at the hospital.
“I note the evidence of RN Comber that since early 2015 there has been an operational policy shift at Toowoomba Hospital such that nurses are now required to document each shift they have in the patient’s chart – this is a change from the process of ‘exceptional reporting’ in place at the time of Mrs Mead’s final admission.
“I can only reiterate the importance of good clinical documentation in all health care settings and encourage ongoing efforts to educate and maintain staff awareness of same.”