‘Mistake’ led to death of Dannevirke identity
Inquest: Two hospitals failed Koro Mullins
Afatal injection of air into one of Dannevirke identity Koro Mullins’ arteries during stent surgery three years ago was most likely enabled by a missed check in the procedure, according to a leading cardiologist.
The most likely explanation, that there was no check for air in the line, was offered at an inquest on Friday by Dr David Smyth.
Dr Smyth, a Christchurch specialist, was not involved in the procedure, but was called on by Coroner Bridget Windley to examine circumstances surrounding the death of Mullins during a percutaneous coronary intervention procedure in Wellington Hospital on September 16, 2019.
Mullins’ wife Mavis and wha¯nau last saw him alive in the late morning and waited, expecting to see him alive, well and recovering by midafternoon.
But instead, three hours later, they were ushered into a room and told he had not survived.
The inquest heard that amid questioning at the time — particularly by daughter Korina, a Hastings nurse — staff conceded there had been “a mistake”.
Smyth, appearing on the fifth day of an inquest which started in Wellington last Monday and ends on Tuesday, said that to the comparatively small intervention community in New Zealand, the circumstances and the impact of the death would be like the impact on the air traffic control community if a 747 jet crashed.
Among the issues being tackled at the inquest is why Mullins was not admitted when first presenting with chest pain at Palmerston North Hospital almost four weeks earlier (August 20), in relation to the hospital’s Accelerated Diagnostic Chest Pain Pathway.
That pathway was described on Friday by Dr Smyth as “mythical” and has been described during the inquest as “non-existent”.
Mullins was sent home that day with relief for musculoskeletal back pain and referred for further investigation, which meant he should have been seen by a cardiologist within 72 hours.
There was no follow-up, and he returned on September 11 reporting intensified pain and a fall at work on the previous day, after which he continued working on the family dairy farm east of Dannevirke.
He was examined, found to have had a heart attack with damage to heart muscle, and was programmed for procedure at Wellington Hospital.
The inquest was told a Palmerston
North Hospital audit recommended by Dr Smyth found that while the pathway was supposed to include a follow-up with a cardiologist within 72 hours, the average patient wait was 129.6 days, and that 38 had died while waiting for follow-ups which had not happened.
Dr Smyth said while the death or severe adverse event rate at Palmerston North was 6.77 per cent, it was just 0.5 per cent at Christchurch, and that such a difference “should not occur”.
In an opening statement read by Mavis Mullins which lasted 45 minutes and went unchallenged during the inquest, the court was told of how, after being informed her husband had died and there had been “a mistake”, she consoled staff by saying she forgave them.
But she had since become concerned about the veracity of the DHBpromised investigation, including the lack of formal interviews of staff — when she had been interviewed by police for over an hour — and the lack of notes, and the enabling of the disposal and cleaning of items and equipment which should have been “frozen”, pending examination, to establish what happened and why.
Mullins was a strong, physical man who had worked hard in the farming industry. Mavis described him as a community man, recognised and well-liked.
He was a legend in the shearing community and had earned international respect for his contribution to it, being part of the world-famous Golden Shears for decades and was a commentator, presenter, and interviewer for the competition.
The inquest continues.