Broken neck undiagnosed
Care before death lacking: Coroner
ROYAL Hobart Hospital staff failed to diagnose a fractured neck in a car crash victim who died from pneumonia just days later, a coroner says.
Fern Tree woman Julie Anne Holmes, 72, did not receive “an acceptable standard” of care following the July 2017 Huon Rd car crash, Coroner Simon Cooper said in his findings released yesterday.
Mrs Holmes was already paralysed on the right side of her body and wheelchairbound after suffering two strokes in 2013. Her husband had left his job at the University of Tasmania to care for her full-time.
The couple was driving home on July 21, 2017, when they had a single-vehicle car crash near Summerleas Rd. Their vehicle slid down an embankment before coming to rest against several gum trees. Firefighters extracted Mrs Holmes from the passenger’s side and put her into an ambulance, with paramedics deeming she had only suffered minor injuries. However, due to her disability, she was transported to the Royal Hobart Hospital.
Ambulance Tasmania officers were concerned she might have a neck injury and put Mrs Holmes in a neck brace – but they removed it when she complained of discomfort and stabilised her head manually on the trip.
That was a “poor decision”, Mr Cooper said. Mrs Holmes underwent a number of scans and X-rays, but “the guideline was not followed” at the hospital to ensure all patients over 65 years old involved in car crashes were cleared of cervical spine injuries.
Over the next two days, Mrs Holmes was still complaining of back and shoulder pain. Her condition “deteriorated markedly”, and she was put on medication to support her blood pressure.
On July 24, an ECG showed Mrs Holmes had right ventricular failure, she began to suffer multi-organ failure, and she died a short time later. An autopsy showed Mrs Holmes died from pneumonia following a cervical spine fracture sustained during the car crash – a fracture “not diagnosed by staff at the Royal Hobart Hospital prior to her death,” Mr Cooper said.
“The evidence indicates that the treatment received by Mrs Holmes was not of an acceptable standard,” he said.
However, Mr Cooper said Royal Hobart Hospital had since reviewed its procedures and implemented new guidelines in November 2017 for cervical spine management.