Inquest clears Emerald Hospital
A CORONER has ruled that the death of Emerald woman Yvonne Davidson was not a direct result of a procedure undertaken at Rockhampton Hospital.
Coroner Annette Hennessy said although Ms Davidson did not recover from the procedure, her critical illness would have only seen her live a further two to three months at most.
These findings were presented in a Rockhampton Coroner’s Court on Wednesday, almost five months after an inquest into the death.The inquest had brought many issues at Rockhampton Hospital into question.
Mrs Davidson, 75, who had a serious medical history, first presented to Emerald Hospital with diarrhoea and flu-like symptoms on September 1, 2007.
She was later flown to Rockhampton Hospital suffering from respiratory distress secondary to pneumonia.
The decision was made to perform a percutaneous tracheostomy, a procedure to clear the airway and allow her to breathe easier, September 9, 2007.
During the procedure, which did not comply with set protocol, Mrs Davidson’s condition deteriorated.
She did not recover.
Coroner Hennessy said Rockhampton Hospital failed to comply with protocol which specified two consultants must be present.
The procedure was actually performed by a junior doctor, who was keen to take learning opportunities, under the guidance of one consultant - Doctor Holland, an intensive care specialist and anaesthetist.
A nurse had earlier shown Doctor Holland the protocol but he did not recall viewing it.
The use of a bronchoscope is also preferred during a tracheostomy, but the one provided for use had a faulty or missing power lead.
Doctor Holland decided not to use it, stating to a nurse he would do the procedure “blind”.
A bronchoscope allows all staff present to view the airway other than just the operator.
Three other bronchoscopes were available in other hospital departments but not sourced that day.
There was also no urgent reason to perform the procedure that day, a Sunday, and a 24 to 48-hour delay would not have compromised Mrs Davidson’s health in anyway.
Coroner Hennessy also identified inconsistency of procedures between Queensland hospitals and poor communication between team members as other issues relating to the inquest.
There was insufficient evidence to take any criminal action against Doctor Holland.
He has instead been disciplined by the Medical Board.
Coroner Hennessy made numerous recommendations for Rockhampton Hospital to implement, including the following:
Ensure the future use of a bronchoscope for tracheostomy protocol
Ensure all equipment is working and available in the intensive care unit
A tracheotomy be performed in normal working hours, unless urgent, to allow skilled personnel to be available
That where protocols or policies have been developed in Queensland hospital, they be shared and communicated to all doctors to ensure best practice and the highest level of patient safety