Coroner's Finding: Harrison, Jason Keith

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Rod Chandler, Coroner, having investigated the death of Jason Keith Harrison Find that:

(a) The identity of the deceased is Jason Keith Harrison;

(b) Mr Harrison was born on 7 January 1981 and was aged 34 years;

(c) Mr Harrison died at the North West Regional Hospital (NWRH) in Burnie on 7 February 2015;

(d) The cause of Mr Harrison’s death was sepsis due to an extensive small bowel infarct caused by bowel incarceration within a congenital mesenteric defect (mesenteric hernia).

Background Mr Harrison was single and lived alone in Queenstown. His mother, Margaret Rose Harrison, resided nearby and he visited her daily. He had a learning disability but otherwise enjoyed good health.

Circumstances Surrounding the Death Mrs Harrison advises that her son visited her in the morning of 6 February 2015. He asked for something to eat and she made him some toast and gave him some cordial. Afterwards Mr Harrison vomited. He then complained that his stomach was sore and getting worse. He said that he had been unable to open his bowels for a few days. He said he was hot and felt weak. He requested his mother call an ambulance, which she did. Mr Harrison continued to vomit. An ambulance arrived after a short delay. Mr Harrison was then transported to the West Coast District Hospital (WCDH). The Ambulance Tasmania (AT) notes show that Mr Harrison reported having woken at 6.00am with “epigastric crampy pain”, that he had vomited, that he was agitated, that he denied consumption of alcohol or use of illicit drugs, and that he claimed to be unable to walk but was able to do so with encouragement. The initial assessment by AT was “gastrointestinal problem.”

The hospital records show that Mr Harrison was triaged at 8.37am. He was noted to be complaining of epigastric pain and vomiting. His clinical observations were blood pressure 127/59, pulse 50, respirations 16, oxygen saturation 100% and temperature 34.8°C. Shortly afterwards he was reviewed by Dr Dennis Pashen. It was noted that Mr Harrison was alert but agitated. It was recorded that Mr Harrison said that he had been to Strahan the previous afternoon and had had some chips and soft drink. He denied any illicit drug use. However, others at the hospital informed Dr Pashen that Mr Harrison had been seen in the company of known drug users. Examination by Dr Pashen showed generalised tenderness over the abdomen with normal bowel sounds, no rebound or guarding. The decision was taken to admit Mr Harrison for further observation. A definite diagnosis was not made at this time.

Intravenous fluids were commenced, a drug screen was ordered, analgesics and medication for gastritis were given and appeared to be beneficial. A review was planned in two hours.

Mr Harrison was reviewed at 2.00pm. It remained difficult to obtain a clear history from him because of his agitation and general demeanour. He refused an ECG. He still complained of upper abdominal pain but the pain seemed not to stress him. It was noted that he denied using medication or illicit drugs. At 2.40pm, nursing staff noted that he was “verbally abusive and threatening to pull out the IV cannula. Client is constantly asking for sedatives stating, ‘I want something to sleep.’” During the afternoon Dr Pashen telephoned the NWRH and enquired about possible illicit drugs that Mr Harrison may have obtained. The NWRH was unable to help. Mr Harrison’s vital signs remained normal. It was decided to continue his observation.

At 8.30pm it was recorded that ongoing management was to continue and that a fluid balance sheet was to be maintained. However, Mr Harrison was not “co-operating with measurement of output.” At 11.30pm it was noted that Mr Harrison had had a shower and was sleeping.

The following morning at 6.30, Mr Harrison informed nursing staff that he was experiencing an urgency to urinate but was unable to void. Assessment found a distended bladder and abdomen. He was tender to touch. Dr Pashen was advised and he directed that Mr Harrison be catheterised. It was then recorded: “Collected 50mL of urine. Not draining.

Informed GP for review of patient.” At 7.15am Dr Pashen reviewed Mr Harrison. His abdomen remained distended and tender.

It was noted that he had passed “minimal urine” and that his observations had been stable until this review, when his respiration rate was elevated. He continued to have generalised pain and tenderness and his analgesia was changed to morphine. The decision was taken to transfer Mr Harrison to the NWRH. In his letter of referral Dr Pashen indicated a diagnosis of “probable bowel obstruction ? cause…..” The ambulance attended at WCDH at 8.36am and departed with Mr Harrison at 9.00am. At Tullah he was transferred to a second ambulance. It arrived at the NWRH at 11.27am. The triage notes state that Mr Harrison was pale and looking unwell on arrival. He was also noted to be tachycardic and tachypnoeic. Shortly after his arrival he became unresponsive.

Resuscitation was commenced. It was overseen by Emergency Medicine consultant, Dr

Brian Doyle, and was maintained for about 30 minutes. However, Mr Harrison could not be revived and he was declared deceased at 12.28pm on 7 February 2015.

Post-Mortem Examination This was carried out by forensic pathologist, Dr Donald Ritchey. In his opinion the cause of Mr Harrison’s death was sepsis due to an extensive small bowel infarct caused by bowel incarceration within a congenital mesenteric defect (mesenteric hernia).

Investigation This has included:

1. Consideration of an affidavit provided by Mrs Harrison.

2. Obtaining Ambulance Tasmania reports.

3. Consideration of a report provided by Dr Pashen.

4. A review of Mr Harrison’s records at the WCDH and the NWRH, carried out by research nurse, Ms L K Newman.

5. Consideration of a report provided by Dr A J Bell as medical adviser to the coroner.

6. Meetings attended by myself, Ms Newman, Dr Bell, Dr Ritchey and State Forensic Pathologist, Dr Christopher Lawrence, to monitor the investigation.

In his report Dr Bell makes these comments:  Abdominal pain can be a challenging complaint for both a primary care and specialist physician because it is frequently benign but it can also herald serious acute pathology.

 The first diagnoses that must be considered in patients with acute abdominal pain are those that may require urgent surgical intervention. The ‘surgical abdomen’ can be usefully defined as a condition with a rapidly worsening prognosis in the absence of surgical intervention. Two syndromes that fit into this category are obstruction and peritonitis.

 The notes of Dr Pashen made at the time of his initial examination represent an inadequate assessment of Mr Harrison. He did not record a diagnosis or a differential diagnosis. The impression given is that drug abuse was suspected and that it was the cause of Mr Harrison’s abdominal pain.

 Mr Harrison’s history, as described by his mother, coupled with the information recorded by AT, should have alerted Dr Pashen to suspected bowel obstruction as a possible diagnosis for Mr Harrison.

 For most patients plain x-rays will quickly confirm a diagnosis of bowel obstruction.

In this instance it seems that Dr Pashen failed to obtain x-rays.

 By 2.00pm on 6 February, the decision should have been taken to transfer Mr Harrison to the NWRH. The reasons are threefold. First, was his unco-operative behaviour and agitation which made his assessment and treatment difficult. Second, was the diagnosis of suspected bowel obstruction. For the reasons stated this should have been in Dr Pashen’s contemplation. Third, the suspicion was that Mr Harrison was suffering from drug abuse. This raised the potential need for managing drug withdrawal, a process which is difficult and can be best managed in a larger and better resourced facility.

 Mr Harrison’s condition required urgent surgery involving a laparotomy with bowel resection. For a person of his age, the prospects of this surgery being successful and Mr Harrison making a full recovery were good.

Findings, Comments and Recommendations I accept Dr Ritchey’s opinion upon the cause of death.

It is apparent, with the benefit of hindsight, that Dr Pashen’s decision to retain Mr Harrison at WCDH and monitor his condition was a misjudgement. The evidence suggests that this decision was overly influenced by the suspicion that Mr Harrison’s presentation was attributable to illicit drug use. Rather, it is my view, accepting the opinion of Dr Bell, that there was sufficient evidence to raise suspected bowel obstruction as an explanation for Mr Harrison’s presentation. This mandated his evacuation to NWRH as this facility was equipped to confirm the diagnosis by CT scan and was resourced to promptly respond with a laparotomy and resection if it became necessary. Such evacuation should have occurred, again accepting Dr Bell’s opinion, during the afternoon of 6 February. I cannot positively find that an evacuation at that time would have guaranteed Mr Harrison’s survival from his bowel obstruction. However, I am satisfied that in this eventuality his prospects of survival would have been greatly enhanced.

This case, along with a recent finding of mine upon the death of Mr Ian Summerfeldt, should serve as a reminder to all small-scale hospital facilities in the State of the need to take a particularly cautious approach when managing patients with potential ‘surgical abdomens’, given their limited capacity to respond in the event of a rapid deterioration in the patient.

I have decided not to hold a public inquest into this death because my investigation has sufficiently disclosed the identity of the deceased, the date, place, cause of death, relevant circumstances concerning how his death occurred, and the particulars needed to register his death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that

the holding of a public inquest would elicit any significant information further to that disclosed by the investigation conducted by me.

I convey my sincere condolences to Mr Harrison’s family and loved ones.

Dated: 16th day of December 2016 at Hobart in the State of Tasmania.

Rod Chandler Coroner