McKenzie, Jillian Peta

OFFICE OF THE STATE CORONER FINDINGS OF INQUEST CITATION: Inquest into the death of Jillian Peta McKenzie TITLE OF COURT: Coroner’s Court JURISDICTION: Cairns FILE NO(s): COR 2610/06(0) DELIVERED ON: 3 October 2008 DELIVERED AT: Cairns HEARING DATE(s): 25 February 2008 and 26 February 2008

FINAL SUBMISSIONS RECEIVED: 2 June 2008 FINDINGS OF: Magistrate A.J.P.Comans, Coroner

REPRESENTATION: Counsel Assisting: Ms Julie Wilson Counsel for Mr Alan Greene, husband of the deceased Mr. D.G.H. Turnbull instructed by Messrs Williams Graham and Carman Counsel for Queensland Health and its employees Mr. Dean P Morzone

CORONERS FINDINGS AND DECISION The death of Jillian Peta McKenzie came to the attention of the coroner at Cairns due to its sudden nature.

An investigation was carried out by the coroner and the husband of the deceased, Mr.Alan Greene made a request under Section 30(1) Coroners Act 2003 for an inquest to be held.

An inquest was held on 25 and 26 February 2008.

At the inquest Mr. Turnbull, counsel for Mr. Greene indicated that Mr. Greene preferred for the deceased to be referred to as Jillian during the inquest. He also preferred to be referred to by his first name, Alan.

Section 45(2) of the Coroners Act 2003 requires the Coroner to make the following findings, if possible – a) who the deceased person is; b) how the person died; c) when the person died; d) where the person died; and e) what caused the deceased person to die Section 46 of the Act allows the Coroner to comment, whenever appropriate, on anything connected with a death investigated at an inquest that relates to – a) public health or safety; or b) the administration of justice; or c) ways to prevent deaths from happening in similar circumstances in the future The deceased person is Jillian Peta McKenzie, born 1 June 1959 at Melbourne, a teacher by occupation and married to Alan for twenty-three years.

Jillian died at her home at Lot 4 McMahon Drive, Fishery Falls in the early hours of 13 September 2006 of natural causes associated with her heart.

The cause of death is as declared on the autopsy certificate completed by Dr Stewart, being 1(a) Cardiac arrhythmia, due to 1(b) Severe coronary artery atherosclerosis

THE CIRCUMSTANCES OF JILLIAN’S DEATH On 12 September 2006, the day before her death, Jillian had been at her workplace and had been unwell all day.

After speaking to her good friend, Julie Irene Cattana, Jillian went home to her residence. There she spoke to her husband Alan and advised him of the pain in her chest.

Jillian rested for a short time and then decided she would like to see a doctor. Ultimately, contact was made with the Babinda Hospital and upon advice from nurses at the hospital that there was a doctor on duty, Jillian and Alan drove there, arriving at about 6.30pm.

Upon arrival, Jillian was placed in an examination room of the hospital and attended to by Registered Nurse (RN) Ann Margaret Barba and Enrolled Nurse (EN) Tanya Lee Barba.

Observations were taken and noted in the hospital file, then an ECG performed.

At the time Jillian presented to the Babinda Hospital, Dr. Richard Adam Lane, a Resident Medical Officer from Cairns Base Hospital was relieving medical officer at Babinda.

Babinda was and still is a level one hospital, having only basic facilities.

Dr. Lane was summonsed by RN Barba and performed an examination of Jillian in the presence of Alan. Both nurses, EN Barba and RN Barba were present at various times during the examination.

The examination was comprehensive and Dr. Lane made notes in the hospital file.

Dr Lane made a diagnosis and there was a conversation between Dr. Lane and Jillian about the results of the examination.

Jillian was given three Brufen tablets by R.N. Barba to take home as per Dr. Lane’s instructions and discharged from the hospital to go home.

On the way home to Fishery Falls, Jillian made a phone call to her good friend Julie Cattana and had a conversation about the events at the hospital.

Upon arrival home, Jillian had something to eat and retired to bed.

In the early hours of the next day Jillian suffered heart failure and died.

THE INQUEST AND FINDINGS At the inquest on 25 and 26 February 2008, the following persons were called and gave evidence: Constable K. Hayes, reporting/investigating police officer Alan James Greene Julie Irene Cattana Registered Nurse Ann Margaret Barba Enrolled Nurse Tanya Lee Barba Dr. Richard Adam Lane Prof. A.F.T. Brown Dr. E.G. Galea Dr.Peter Pereira Dr. Kathleen Atkinson Registered Nurse Joanne Riggs At the inquest the coroner was assisted by Ms Julie Wilson, Counsel of the Office of the State Coroner, Mr. Dean Morzone of counsel appeared for Queensland Health and its employees and Mr. D. Turnbull of counsel appeared for Mr Greene.

There is some conflict in the evidence about how the events surrounding Jillian’s visit to the Babinda Hospital transpired.

The issues that emerge from the evidence are these: Was contact made with the Cairns Base Hospital by Jillian or Alan at all prior to making contact with the Babinda Hospital?

Was there any reluctance expressed or shown by Jillian or Alan to attending the Cairns Base Hospital?

What was Dr. Lane’s diagnosis after his examination of Jillian and what information or advice (if any) was given by Dr. Lane to Jillian about the condition she presented with?

What was Jillian’s reaction to the diagnosis and the information or advice (if any) given by Dr.

Lane?

Taking firstly the issue of whether there was prior contact with Cairns Base Hospital and reluctance to attend there due to possible waiting.

Julie Cattana gave evidence of the conversation with Jillian on the way home from the Babinda Hospital. In that conversation Julie Cattana said Jillian referred to a phone call Alan had made to the Cairns Base Hospital and that he was advised there was a seven hour wait. That was stated in reply to Ms Cattana’s inquiry about why they had gone to Babinda Hospital.

That alone convinces me that Alan did make a call to Cairns Base Hospital after he telephoned the Gordonvale Medical Centre on the evening of 12 September 2006.

With respect to any reluctance to attend the Cairns Base Hospital: Whilst Alan denies there was any such reluctance by either Jillian or himself, the evidence of RN Barba indicates otherwise.

I accept RN Barba’s evidence about what was said to Alan on the telephone. The conversation as related by RN Barba in her statement and to the court is consistent with the fact Jillian had worked all day at Cairns and with the prospect of a seven hour wait at Cairns Base Hospital.

I am satisfied there was some reluctance on the part of both Jillian and Alan to attend Cairns Base Hospital.

The remainder of the issues referred to above have arisen because of the conflict in the evidence between Alan and Dr Lane and to a lesser extend between Alan and RN Barba and EN Barba.

With respect to any conflict of evidence between Alan and both RN Barba and EN Barba, I find I accept the version given by both nurses.

RN Barba made notes in the hospital file and even Alan concedes that he may not have heard all the conversation between Jillian and the nurses before Dr Lane came into the room.

That evidence reveals that Jillian reported pain during the day, no pain at presentation but a revival of pain later in the examination. The pain was around her left breast through to her shoulder blade.

The main area of conflict is between Alan and Dr. Lane.

There is no doubt that Dr. Lane carried out a thorough and proper medical examination.

Alan maintains that at no time did Dr Lane discuss with Jillian the issue of any possible heart condition being the source of the pain, nor the desirability of having blood tests to eliminate heart problems as the source of the pain or the inability to carry out those tests at Babinda.

Alan also maintained there was no second conversation with Dr Lane in the corridor and that at no time did Dr Lane mention the desirability or need to attend Cairns Base Hospital that night to have tests to eliminate heart as the source of pain.

Alan did concede that Dr Lane said “if the pain is still there in the morning, come back and we’ll do some more tests across the road”.

Dr Lane’s evidence reveals a somewhat contrary view on several important points.

Dr Lane’s position is that he did diagnose the source of the pain was most likely muscular - in fact in evidence he stated he advised Jillian it was 99% muscular.

There was evidence from Dr Lane that Jillian expressed some reluctance to go to Cairns after he informed her the test could only be done that night in Cairns.

Dr Lane related a further conversation he said he had with Jillian in the corridor.

The gist of that conversation was according to Dr Lane, that he could not eliminate heart 100% without the troponin blood tests; that Jillian could go to Cairns that night to have the blood tests

done and that is what he recommended; that Jillian expressed reluctance to going to Cairns that night; and finally that he stressed the following “if it’s heart we need to know about that tonight, it’s serious”.

My assessment of the evidence is that it is more likely than not that Dr Lane did have a conversation with Jillian about blood tests and not being able to 100% eliminate heart as the source of the pain without the blood tests.

I find it highly unlikely that there was no discussion between Jillian and Dr Lane about heart as maintained by Alan.

In support of that it must be common ground that everyone present, Jillian, Alan the two nursing staff and Dr Lane were all cognisant of the fact that Jillian had chest pain and the elimination of heart as the source of pain was a major consideration. In that regard, the nursing staff did an ECG, troponin blood testing was discussed by Dr Lane with the nursing staff, and Alan in his statement stated that he and Jillian were relieved that heart had been eliminated when they left the hospital.

I find it implausible that Dr Lane would not have discussed these matters with Jillian. There is reference in Dr. Lane’s notes about returning in the morning for “tests” and Alan recalls conversation about returning in the morning for “tests”.

Alan’s memory of what conversations occurred cannot be regarded as absolutely reliable – there was obviously a lot of the conversation between Jillian and Dr Lane during the thorough examination by Dr Lane (see the notes for instance) and the examination of Alan by Mr Morzone revealed that he did not recall most of the conversation during the examination by Dr. Lane.

I accept there was probably a second conversation in the hallway. Alan recalls that Dr Lane was present in the corridor with Jillian and himself, but maintains that Dr Lane said nothing to Jillian.

I am inclined to prefer Dr Lane’s memory over Alan’s, but do not believe the conversation was as significant as Dr. Lane attested to.

I find that it is more likely than not that Dr.Lane did advise Jillian about the blood tests being available to eliminate heart and that that could only happen that night at Cairns. I cannot say positively that Dr Lane made an offer to arrange ambulance transport to Cairns that night – he

may have, but there are no notes of such an offer and no one else recalls such an offer being made.

However the main point is that at no time did Dr Lane advise Jillian that as a matter of any urgency she should go to Cairns to have the tests done that night.

There is no record in the hospital notes of any firm advice being given to go to the Cairns Base Hospital that night and Dr Lane himself in his statement confirms he did not forcefully recommend Jillian have the blood tests that night.

Whilst I accept that Dr Lane made general statements to Jillian about the need for blood tests to 100% eliminate heart as the source of the pain and about the blood tests being available that night only in Cairns, those statements were all made in the context that he was 99% sure the source of the pain was muscular and that Jillian was at low risk of any heart problems.

Unfortunately Dr Lane was not aware of the protocol of a patient remaining in the intermediate risk category until the ECG and blood tests have been done and then repeated several hours later.

The proposition that clear firm advice was given by Dr Lane to Jillian to go to the Cairns Base Hospital that night and then rejected by Jillian is not consistent with the circumstances that actually existed – that is Dr Lane’s near absolute diagnosis of muscular pain and classifying Jillian as low risk of a heart problem.

I have accepted there was some reluctance by Jillian and Alan to go to Cairns Base Hospital due to the prospect of having to wait. However, I do not accept that there has been any rejection by Jillian of clear firm advice to go to Cairns Base Hospital that night.

In fact, I am unable to find that any firm or forceful statement such as “if it’s heart we need to know about that tonight, it’s serious” was ever made.

It is against this background of a near absolute diagnosis that the source of the pain was muscular and that Jillian was in the low risk category of having a heart problem that Jillian and Alan left the hospital and went home.

During the investigation phase of this matter, Professor Brown gave a report to the Coroner and subsequently gave evidence at the Inquest.

I accept Professor Brown’s opinions expressed in that report. I note the opinions of Drs.

Atkinson and Pereira about matters of procedure in assessing patients who present with chest pain, but defer to Professor Brown where there is any conflict.

Professor Brown concluded that it was an error of judgment for Dr. Lane to send Jillian home.

It was an error to state in so near absolute terms that the source of the pain was 99% muscular.

Professor Brown pointed out that the National Heart Foundation Guidelines (and the guidelines in force at the Babinda Hospital at the time) required Jillian to remain classified at intermediate risk of acute coronary syndrome (ACS) until the ECG and the blood tests had been done and then repeated several hours later.

To send Jillian home in the circumstances was contrary to the guidelines for the management of patients with chest pain.

The proper course, based on Professor Brown’s evidence was to follow the National Heart Foundation Guidelines (annexed to his report):

• Classify Jillian as at intermediate risk of ACS

• Admit her to hospital – as Babinda is a level one hospital with no facilities to monitor chest pain patients and had no facility to do the blood tests immediately, admission to hospital would have to be by transport to Cairns Base Hospital

• Perform an ECG and blood tests for troponin levels

• monitor

• Repeat the ECG and blood tests then make a diagnosis from that point and assess the risk of ACS.

It was recognised by Professor Brown and other professional witnesses that patients have the right to reject advice.

Whilst I have accepted that Dr Lane did, without doubt, perform a thorough examination with the intention of assessing the risk of the source of the pain being a heart problem and that in all probability Dr Lane did explain that heart could only be 100% excluded by blood tests and that those blood tests were not available in Babinda that night, only in Cairns, there was no firm clear advice given to Jillian that she should go to Cairns that night nor was any sense of urgency asserted by Dr. Lane.

This is not a case of a patient rejecting clear, firm advice.

The likelihood of Jillian dying even if she had been transported to and admitted to Cairns Base Hospital that night was raised.

From the evidence of Professor Brown, Dr. Galea and Dr. Pereira, it’s clear there are quite a few variables to consider:

• The mechanism of death

• Availability of facilities ( beds, monitors, staff)

• Hospital policy of the use of monitors on intermediate risk patients The matter of the exact mechanism of death (whether ventricular tachycardia or ventricular fibrillation or immediate asystole) seems quite crucial in considering this question. Both Dr.

Galea and Professor Brown gave opinions about this, but agreed ultimately it would be speculating to try to come to any positive conclusions.

I do not propose to make any positive findings on this topic. It is not necessary in a factual sense and not necessary to extend any comment into the area of treatment of patients who are actually admitted to hospital, as Jillian was not admitted.

Comment will be confined to the circumstances of a patient attending a level one hospital with chest pain and treatment at that hospital.

I do however find as a matter of fact that Jillian would have had a better chance of surviving the event had she been in a hospital rather than at home.

CONCLUSIONS At the outset of this inquest it was submitted by all parties that the following matters were the issues to be canvassed:

• Was the level of care, treatment and advice provided by the staff at Babinda Hospital adequate and appropriate in all the circumstances?

• Was it reasonable in the circumstances that Jillian was not transferred and or referred to the Cairns Base Hospital for further observation and or treatment?

• The steps taken by Queensland Health to address any inadequacies that existed at the time of Jillian’s death and the sufficiency of those steps.

I find that the care, treatment and advice given by the nursing staff at the Babinda Hospital was without doubt adequate and appropriate in the circumstances.

With respect to Dr. Lane, I find that the examination was thorough and professional and the diagnosis that the source of the pain was muscular in origin was a reasonable one. Dr. Lane fell into error by not following the National Heart Foundation Guidelines for the management of acute coronary syndromes 2006 (or the guidelines in the Cairns Base Hospital document “Management of Acute Coronary Syndrome). By following those guidelines and notwithstanding the diagnosis of muscular pain, Dr Lane should have assessed Jillian at intermediate risk of ACS in the absence of an ECG and blood tests followed by further ECG and blood tests. Whilst Dr Lane recognised that a heart problem could not be 100% eliminated without the blood tests, it was a mistake for Dr Lane to say he was 99% sure the source of the pain was muscular and to assess Jillian as low risk of having a heart problem.

Jillian should have been informed by Dr Lane firmly and clearly and in layman’s terms that without blood tests she was at intermediate risk of heart failure and then offered transport by ambulance to the nearest facility where those tests could be carried out without delay. It is then a matter for a patient such as Jillian to make an informed decision whether to go home or to hospital.

COMMENT UNDER SECTION 46 The following comments are made in relation to public health and safety: Broadly speaking, Queensland Health has, in the opinion of Professor Brown, taken all steps necessary in response to Jillian’s death.

In his report dated 16 March 2007, Professor Brown commented on the circumstances of Jillian’s death, gave opinion about the standard of care given to Jillian, came to certain conclusions and made recommendations for the future.

Dr. Simi Sachdev, Acting Executive Director of Medical Services at Cairns responded on 6 July 2007 to the material submitted to the Coroner, including Professor Brown’s report. Dr. Sachdev outlined all the steps taken from the time of Jillian’s death to address the matters raised in Professor Browns report.

In his supplementary report dated 1 November 2007, Professor Brown commented on Dr. Simi Sachdev response: At A4 and A5 on page 5 The submission appears to have covered all relevant issues raised relating to the past and present management of a patient with chest pain and or suspected acute coronary syndrome (ACS) at Babinda Hospital.

I believe that every concern raised in my report of 16 March 2007 on behalf of the Coroner has been addressed.

Professor Brown then set out the measures that have been taken at the Babinda Hospital by Queensland Health in response to Jillian’s death (see B1 to B6 of the supplementary report).

Professor Brown then concluded by saying (at B7): I agree completely with Dr Sachdev that the above measures taken at Babinda Hospital represent a significant improvement towards the management of acute coronary

syndromes, which I believe will henceforth allow Babinda Hospital to practise at the highest level of quality care currently available to such a hospital.

RECOMMENDATION NO. 1 I recommend that the appropriate authorities in Queensland Health ensure that the measures taken at Babinda Hospital ( referred to in B1 to B6 of Professor Brown’s supplementary report) in response to Jillian’s death are implemented at all level one hospitals in Queensland.

The final matter for comment is about staffing of level one hospitals by junior doctors.

This is a proper matter for comment and there were strong views expressed about this issue by senior medical practitioners from Cairns and Professor Brown during the inquest.

Dr. Pereira in response to the following question by Ms Wilson, Counsel assisting the Coroner: Q. Can I ask you to comment on the appropriateness of sending a doctor with Dr. Lane’s lack of experience to Babinda to essentially be the only doctor available at that hospital?

A. I have a very strong philosophy in my department that junior medical officers of this type are supervised and have access to direct supervision.

The evidence of Dr Lane was that he had no such supervision and no access to direct supervision.

Dr. Atkinson, Executive Director of Medical Services for the Cairns Base Hospital and the Cairns and Hinterland Health Service District responded to the following question by Ms Wilson: Q I want to ask you about the evidence that has been given about the appropriateness of a Dr – with Dr Lane’s experience being sent to Babinda essentially on his own. You have heard the evidence of Dr (Professor) Brown and Dr Pereira who have expressed to us that it’s inappropriate to send a first year post-registration doctor to a hospital like Babinda on their own. Can you provide the court with your opinion in that regard?

A I can certainly provide you with my personal opinion which is based on 25 years of rural practice and having worked in an isolated location as a junior doctor unsupported. I would hope never to see it again because it has many, many counter- productive sequels, one of which is that you end up with a young doctor like Dr Lane totally removed from any possibility of ever working in rural medicine again. I don’t disagree that young doctors need to get some rural experience, but what we must do is put (in) a safety net and a support structure around them.

Dr. Atkinson then gave evidence on the topic of sending young doctors to hospitals such as Babinda to carry out their duties on their own and what safety net and support structures there are now available or proposed to become available.

Dr Atkinson commented (at 91 par 25) …what we’ve tried to do is put as much support around these doctors as we can, and my personal view is as Professor Brown’s and Dr. Pereira’s is, is that we shouldn’t be sending second year doctors out.

Dr Lane was a second year doctor, having completed his compulsory intern training which is first year doctoring.

Professor Brown (at pages 17 and 18 of his evidence) expressed a strong view that junior doctors should not be sent to hospitals where they are the sole doctor in charge. If they have to be sent, then the most senior should be sent with clear lines of communication established so cases may be discussed clinically at a single point of contact.

The support that Dr. Atkinson referred to falls into the following areas: Having clear lines of communication set up and available for junior doctors in isolated hospitals such as Babinda to access senior practitioners at all times. In that regard there is an orientation manual at Cairns Base Hospital and an Orientation Booklet for Medical Staff at Babinda Hospital. Dr. Atkinson suggested these two documents be placed on the hospital’s intranet so the telephone numbers could be available at short notice.

Before being sent to relieve at hospitals such as Babinda, a second year doctor complete the Continuing Rural Skills Enhancement Course and have completed the junior doctor curriculum framework by completion of the competencies based modules.

Awareness of and use of the State-wide Clinical Coordination Retrieval Service.

RECOMMENDATION NO. 2 It is recommended:

• that if a junior doctor is sent to relieve at a hospital such as Babinda, that the most senior available doctor be sent.

• that if a second year doctor or any other junior doctor is to be sent to relieve at a hospital such as Babinda, then only a doctor who has completed the Continuing Rural Skills Enhancement Course and who has completed the junior doctor curriculum framework by completion of the competencies based modules should be sent.

• that there be clear lines of communication set up for all junior doctors relieving at hospitals such as Babinda to access senior practitioners at all times.

Before closing the Inquest I wish to extend my condolences on behalf of the Coroners Court to Jillian’s husband Alan, and Jillian’s relatives and friends for their loss.

Magistrate Alan Comans

CORONER