On-call doc’s phone flat, inquest finds
AN ON-CALL doctor at a Darling Downs hospital did not have his phone charged when a nurse repeatedly tried to call him about the deterioration of an elderly patient, who later died.
Deputy State Coroner John Lock said the failure of Dr John Hall, Oakey Hospital’s medical superintendent, to have his phone charged or give an alternate number was “inexcusable”.
“Errors, misunderstandings and miscommunications” by medical staff at two Darling Downs hospitals contributed to the deaths of the woman, 86, and a teenager, Mr Lock found.
Mr Lock was delivering findings into the sepsis-related deaths of Verris Dawn Wright, 86, at Oakey Hospital in 2013 and Jasmyn Carter, 17, at Warwick Hospital eight months later in 2014.
Mr Lock said nursing staff did not recognise the seriousness of Mrs Wright’s condition and did not have a “plan B” when a nurse could not contact Oakey Hospital’s Dr John Hall.
Mrs Wright died from septic shock due to a bowel obstruction on December 26, 2013, after not being reviewed by a hospital doctor or given any treatment over a fourhour period.
She had gone to the hospital two days earlier with abdominal pains, but was thought to have a urinary tract infection and was sent home without an X-ray.
“There were a series of almost unbelievable errors, misunderstandings and miscommunications which contributed to this tragic set of events,” Mr Lock said.
Jasmyn Carter died from meningococcal septicaemia after an unexplained drop in blood pressure that should have prompted an emergency response, Mr Lock said.
She was admitted to Warwick Hospital a day after complaining of headaches, dizziness and aches and was given intravenous fluids.
Mr Lock said there was no plan for more frequent observations or a review by the oncall doctor because of errors, misunderstandings and miscommunications.