Coroner's Finding: Attwood, Maurice

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Robert Webster, Coroner, having investigated the death of Maurice Attwood Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Maurice Attwood (“Mr Attwood”); b) Mr Attwood died as a result of hospital acquired pneumonia subsequent to the surgical repair of a right sided fracture to the neck of the femur which occurred as a result of a fall at home; c) Mr Attwood’s cause of death was hospital acquired pneumonia; and d) Mr Attwood died on 27 February 2020 at Lenah Valley, Tasmania.

In making the above findings, I have had regard to the evidence gained in the comprehensive investigation into Mr Attwood’s death. That evidence includes:  The Police Report of Death for the Coroner;  Calvary Health Care Tasmania Death Report to Coroner;  Affidavits establishing identity and life extinct;  Report of Dr Donald Ritchey, forensic pathologist;  Affidavit of Mr Anthony Attwood;  Medical Records obtained from Sorell Family Practice and Calvary Healthcare; and  Report of Dr Anthony Bell MB BS MD FRACP FCICM, the Coronial Medical Consultant.

Background Mr Attwood was born on 7 January 1934 at Carlton in Victoria. He was 86 years of age, retired and he resided with his wife of 63 years, Pamela, at the date of his death. Mr and Mrs Attwood had 2 sons, the eldest being Anthony and the youngest being Phillip. During his life, Mr Attwood was a chief petty officer/steward in the Royal Australian Navy in which he served for approximately 20 years. As a result of this occupation his son, Anthony, says the family moved around Australia “quite a bit.” In 1974 the family moved to Gravelly Beach which is situated on the western shore of the Tamar River in northern Tasmania.

Mr Attwood’s Health Mr Anthony Attwood says when he was growing up he recalls his father being a healthy person who never really had any significant health concerns. Mr Attwood was a smoker when he was younger but he gave up smoking about 40 years ago. He was never a heavy drinker. However, in the last few years prior to his death, Mr Anthony Attwood and the medical records reveal Mr Attwood was diagnosed with a number of medical conditions which included a stroke in or about 2014, hypertension and atrial fibrillation, asbestosis, pulmonary fibrosis and a further stroke in December 2019. Mr Attwood was also diagnosed with hypercholesterolaemia and dysphagia(difficulty swallowing) with a large oesophageal pouch. In addition he was diagnosed with monoclonal gammopathy. A number of these conditions were diagnosed in 2018 after medical advice was sought due to Mr Attwood losing between 20 and 25kg in weight over about an 18 month period.

The Circumstances Leading to Mr Attwood’s Death On 14 February 2020, Mr Attwood was taken to the Royal Hobart Hospital after suffering from aspiration. Mr Anthony Attwood says he was discharged after a day as the hospital could do little for him. The family were requested to monitor him over the next few days.

On 17 February 2020, Mr Anthony Attwood says he was going to see his father at home when he was found sitting up in the bedroom. Mr Attwood told his son he had fallen in the bedroom while picking up a sun hat and had overbalanced. An ambulance was called and Mr Attwood was transported to Calvary Hospital in Lenah Valley where he was diagnosed with a right-sided fractured neck of the femur. An operation to repair the fracture could not take place until the blood thinners which Mr Attwood was prescribed had worn off. That surgery

took place on 19 February 2020 and Mr Attwood was walking with the assistance of a frame the following day. He was provided with a number of physiotherapy exercises to assist in his recovery.

While in hospital the family was informed of concerns for Mr Attwood’s nutrition. Due to Mr Attwood’s swallowing difficulties, medical staff advised the family of other interventions they could perform to assist with Mr Attwood’s eating. A specialist saw Mr Attwood in relation to that.

On 25 February 2020, Mr Attwood was having difficulty breathing. He was diagnosed with an infection and provided with oxygen before being transferred to the critical care unit on 26 February 2020. Despite the administration of antibiotics and high flow oxygen, Mr Attwood’s condition deteriorated further. At approximately 8.30am on 27 February 2020, he suffered a cardiorespiratory arrest. The notes of Dr Siejka indicate resuscitation was not warranted as there was a non-shockable rhythm. He certified life extinct at 8.44am on 27 February 2020.

Investigation The forensic pathologist, Dr Ritchey, performed a post-mortem examination and considered the records obtained from Calvary Hospital. He noted a number of Mr Attwood’s preexisting health conditions and reported on 28 February 2020 that Mr Attwood died as result of hospital acquired pneumonia. Dr Ritchey’s report says at the time of death Mr Attwood was recovering from an open reduction and internal fixation of a fracture to the neck of the femur on the right side which was sustained in a fall from a standing position. Dr Ritchey says Mr Attwood died 10 days after the fall and 8 days after he underwent the orthopaedic procedure to repair the fracture.

Because Mr Attwood died while receiving medical treatment at Calvary Hospital, Dr Bell was engaged to examine the standard of medical treatment and care Mr Attwood received.

In his report Dr Bell notes Mr Attwood’s past medical history of significance and the medications he was prescribed immediately prior to his death. In addition to the history of treatment provided by Calvary Hospital set out above, Dr Bell notes Mr Attwood was reviewed by a speech pathologist and a physiotherapist prior to the femur being surgically repaired on 19 February 2020. Dr Bell notes Mr Attwood’s condition on 20 February 2020 was described as stable and a dietician’s review found him to be suffering severe malnutrition. He was considered to be 25kg underweight. On 21 of February 2020, he was mobilising with a frame and sitting out of bed. On 24 February 2020, Mr Attwood was

coughing up brown sputum and he required oxygen therapy. There were bilateral basal crepitations and a localised right basal wheeze. He endured a restless night. On 25 February 2020, a chest x-ray showed bilateral lung base consolidation suggestive of hospital acquired pneumonia. Mr Attwood deteriorated over the day with the development of delirium.

Antibiotic treatment was commenced intravenously. On 26 February 2020, Mr Attwood had further deteriorated with respiratory failure with hypoxia. Mr Attwood died the next day.

Dr Bell says “[t]he patient had major medical issues prior to the fall at home. After the fall the patient’s chance of survival was small. The management in hospital was of good standard with good interaction between the nursing staff and allied health professionals.” Dr Bell’s conclusion is there were no medical issues with respect to the treatment and care received by Mr Attwood. I accept Dr Bell’s opinion.

Dr Bell says after the fall Mr Attwood’s chance of survival was small because he had dysphagia with an increased risk of aspiration. This was established on a radiological swallowing video. He had severe malnutrition most likely related to the dysphagia. The malnutrition impairs the immune response as does age. Malnutrition also impairs the ability to heal as does old age. The dysphagia is likely to be worse with potent analgesics which are required both before and after surgery. In addition Mr Attwood had underlying lung disease with diagnosed asbestosis and pulmonary fibrosis. One reason for performing the surgery is pain relief which is provided by fixing the fracture. Dr Bell says without that surgery there was no chance of survival and in addition Mr Attwood may have suffered significant pain. It is therefore because of Mr Attwood’s comorbidities that Dr Bell says after the fall at home Mr Attwood’s chance of survival was small.

Comments and Recommendations For the reasons set out above, I am satisfied that the medical treatment and care Mr Attwood received at Calvary Hospital from 17 February 2020 until his death on 27 February 2020 was of a good standard.

The circumstances of Mr Attwood’s death are not such as to require me to make any comments or recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of Mr Attwood.

Dated: 23 February 2022 at Hobart Coroners Court in the State of Tasmania.

Robert Webster Coroner