Bro­ken neck un­di­ag­nosed

Care be­fore death lack­ing: Coroner

Mercury (Hobart) - - NEWS - AM­BER WIL­SON Court Re­porter

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.

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