A CORONER has recommended nursing records at Glen Innes Hospital be audited every six months, following the death of a 75-year-old grandmother from septicaemia.
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Deputy State Coroner Harriet Grahame also recommended an orthopaedic specialist who had worked at Armidale Hospital be referred to medical authorities over his conduct in respect to the grandmother's death.
Magistrate Grahame made her findings into the inquest of Maureen Anne Smith, a "strong and independent woman" who had been a kind neighbour and often minded her grandchildren.
Ms Smith died of septicaemia, a painful and often fatal poisoning of the blood, at Armidale Rural Referral Hospital on April 1, 2018 after being transported from Glen Innes District Hospital.
The inquest, which had been delayed because of COVID restrictions, concluded on August 23.
Magistrate Grahame was scathing of evidence given at the inquest by Dr Jauncy Natukokona, also known as Robert Hakwa.
He had been an orthopaedic registrar in Australia for 15 years and was the on-call orthopaedic specialist at Armidale Hospital on the day of Ms Smith's death.
Magistrate Grahame recommended Dr Natukokona's evidence at the inquest be "treated with caution" and that a number of his explanations regarding Ms Smith's treatment and subsequent death were "inherently implausible".
"I remain concerned about the doctor's honesty and capacity to engage with this inquiry with openness and insight," Magistrate Grahame said.
She agreed with counsel assisting the inquest that Dr Natukokona had made a number of unsafe decisions over the care of Ms Smith, such as directing a junior locum to withhold treatment of antibiotics.
Dr Natukokona should also have followed up more proactively in relation to Maureen's transfer and care, Magistrate Grahame found.
The inquest heard how Ms Smith had been a fit and healthy woman until she turned 50, when, while working as a cleaner, she suffered a fall that led to back surgery.
In 2009 she suffered further injuries when a motorbike fell on her, after which she was diagnosed with a chronic illness that arose from an ulcer in her left hip.
By March 2018, her son and neighbour noticed a sharp decline in the grandmother's health.
She was admitted to Glen Innes Hospital on March 31, suffering uncontrolled pain.
The admitting locum consulted with his more senior colleague in Armidale, Dr Natukokona, and they decided the best form of treatment would be a knee aspiration at Armidale Hospital.
But the inquest was told of "systematic errors which caused Maureen's transfer to be delayed overnight [that] had the cascading effect of delaying the commencement of antibiotic treatment".
Ms Smith died shortly after her eventual transfer to Armidale the following morning.
The inquest heard evidence from 11 nurses over Ms Smith's death.
Between 8.45pm on March 31 and 2pm on April 1, just one set of observations were recorded; no records or fluid balance charts were kept, despite hourly rounds of patients, an omission that troubled the coroner.
As a result, Magistrate Grahame recommended a twice-annual audit of nursing records should be undertaken at Glen Innes Hospital, including the use of standard observation charts, the use of fluid charts, recording of hourly rounding and recording of observations.
Magistrate Grahame was also critical of the delay in transferring Ms Smith to Armidale Hospital.
While not criticising individual nurses, the coroner agreed with counsel assisting that "no action was taken to escalate [Ms Smith's] care despite her decline" and that "these failures represented serious departures from an acceptable standard of care and were missed opportunities".
Following the inquest, Hunter New England Local Health District has implemented a number of improvements at Glen Innes Hospital.
These include:
- Providing comprehensive training to staff on identification and management of sepsis and delirium;
- Developing new guidelines for management of a septic joint, where patients are provided antibiotics prior to their transfer to another health facility if not completed within 12 hours;
- Updating after-hours specimen processing protocols in partnership with NSW Pathology, to ensure sepsis blood cultures are deemed an emergency and processed accordingly, and
- Providing ongoing training to new staff at orientation on the clinical handover process for patients transferring to another health facility.
Executive Director, Rural and Regional Health Susan Heyman offered her condolences to Ms Smith's family and apologised that authorities did not provide her with the standard of care she deserved.
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