Coroner's Finding: Ridgeon Beryl Jean

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Simon Cooper, Coroner, having investigated the death of Beryl Jean Ridgeon Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Beryl Jean Ridgeon; b) Mrs Ridgeon died in the circumstances set out below; c) The cause of Mrs Ridgeon’s death was haemopericardium; and d) Mrs Ridgeon died on 17 December 2019 at 2/32 Nicholls Street Devonport, Tasmania.

Introduction In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Mrs Ridgeon’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• An opinion of the pathologist who conducted the autopsy;

• The results of toxicological analysis of samples taken at autopsy;

• Affidavits confirming identification and life extinct;

• Medical reports and records from Tasmania Health Service;

• Report by Dr A J Bell, medical advisor to the Coronial Division; and

• Final RCA Report by the Tasmania Health Service.

Background Beryl Jean Ridgeon was born Beryl Jean Runacres on 23 August 1936 in Lowestoft, Suffolk, England. At the time of her death she was aged 83 years and lived in Devonport, Tasmania.

Mrs Ridgeon was born to the marriage of Charles and Alice Runacres and she had three siblings.

Mrs Ridgeon grew up in England, attending local schools. Upon leaving school, she completed training as a nurse, including specialist training in respiratory nursing at Royal Papworth Hospital.

In 1960, Mrs Ridgeon married Tony Ridgeon. Together the couple had five children: Ann in 1961, Peter in 1963, Mary in 1964 and twins Tony and Wendy in 1970. The family migrated to Australia in 1965 and settled in Burnie, Tasmania.

While raising five children, Mrs Ridgeon worked as a registered nurse at the Burnie Hospital in the ICU. When the family moved to Devonport in 1974, Mrs Ridgeon worked at the Women’s Division of the Mersey General Hospital, including some time as a theatre nurse, until she retired.

Mrs Ridgeon’s husband passed away in 1997.

It is evident that she enjoyed a close relationship with her adult children, which continued until her death.

Circumstances of Death The evidence indicates that from Sunday, 15 December 2019 Mrs Ridgeon felt unwell, and in particular was unable to keep food down. Later in the afternoon, she ate a piece of toast, which was followed by her vomiting into the kitchen sink.

She ate nothing that night for dinner.

In the morning of Monday, 16 December 2019, Mrs Ridgeon was still feeling unwell and unable to eat. Mid-morning, Mrs Ridgeon was taken by her daughter Ms Wendy Ridgeon to the nearby Mersey Community Hospital. A diagnosis of gastroenteritis was made at the Hospital.

Critically, whilst at the Mersey Community Hospital an ECG was performed. That ECG showed clearly that Mrs Ridgeon had suffered a myocardial infarction. The fact that she had suffered a myocardial infarction appears to have been completely missed by medical staff at the Mersey Community Hospital.

Accordingly, Mrs Ridgeon was given Metoclopramide to help her nausea and discharged.

Another daughter, Ms Mary Levett, drove her home.

At home, Mrs Ridgeon was still unwell and unable to tolerate much by way of food or drink.

Shortly before she went to bed at 10.00pm, Mrs Ridgeon vomited. At about midnight, Mrs Ridgeon got out of bed to go to the toilet. At 1.30am on 17 December 2019 Ms Levett, who was staying with her, heard her mother cough once.

The following morning at about 7.00am, Ms Levett found her mother dead in bed.

After formal identification to attending police, Mrs Ridgeon’s body was taken by mortuary ambulance to the Royal Hobart Hospital. At the Royal Hobart Hospital, experienced forensic pathologist, Dr Jane Vuletic performed an autopsy. Dr Vuletic found that the direct cause of Mrs Ridgeon’s death was a haemopericardium, underlying conditions being a ruptured acute myocardial infarction and coronary atherosclerosis.

I accept her opinion as to Mrs Ridgeon’s cause of death.

Ante-mortem testing was completed on a blood sample taken from Mrs Ridgeon upon her visit to the Mersey Community Hospital before she died. That analysis was unremarkable. No alcohol or illicit drugs were found to have been present in the samples. The only drug present were therapeutic levels of Diltiazem.

In summary, Mrs Ridgeon died as a result of a cardiac condition that was clearly and unequivocally identified by an ECG carried out at the Mersey Community Hospital, the day before her death. The fact of that cardiac condition was not identified at the Mersey Community Hospital and she was discharged with medication for nausea.

The Tasmanian Health Service conducted a Root Cause Analysis in relation to Mrs Ridgeon’s death. In its conclusion the RCA report says: “The early diagnostic category of gastroenteritis led to an anchoring of this diagnosis throughout, with no exploration for [sic] alternative or differential diagnosis including acute coronary syndrome. This led to the ECG not being formally ordered as part of the medical workup; rather as a routine process, which led to the missed opportunity to diagnose an acute ST elevation myocardial infarction which was evident on the ECG. This led to the patient being discharged with an undiagnosed acute myocardial infarction.

All ECG’s [sic] should be reviewed, interpreted and signed off by the senior clinician on the floor.

The RCA Team establish there was a missed opportunity to diagnose the acute ST elevation myocardial infarction on ECG. There was a missed opportunity to consider possible medical intervention or treatments.” In my view, the passage summarises very well what went wrong in this case.

Comments and Recommendations The circumstances of Mrs Ridgeon’s death require me to comment that it is imperative staff at the Mersey Community Hospital receive appropriate training in how to interpret the results of ECGs. If the ECG here been properly interpreted, Mrs Ridgeon may not have died.

I convey my sincere condolences to the family and loved ones of Mrs Ridgeon.

Dated: 23 November 2020 at Hobart in the State of Tasmania.

Simon Cooper Coroner