Finding into death of Angela Budaj

Rule 60(1)

FORM 37

FINDING INTO DEATH WITH INQUEST

Section 67 of the Coroners Act 2008 .

Court reference: 662/07

Inquest into the Death of ANGELA BUDAJ

Delivered On: Delivered At: Hearing Dates: Findings of: Representation: Place of death:

"SCAU:

5 and 6 February, 2009 at

PETER WHITE

Mr Chris Winneke for Western Health

30 Moffat Street, St Albans, Victoria 3021

Senior Constable Kelly Ramsey

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 662/07

In the Coroners Court of Victoria at Melbourne J, PETER WHITE, Coroner

having investigated the death of:

Details of deccased: Sumame: BUDAJ Firstname: ANGELA ; Address: 30 Moffat Street, St Albans, Victoria 3021

AND having held an inquest in relation to this death on 5 and 6 February, 2009 at Southbank

find that the identity of the deceased was ANGELA BUDAI

and death occurred on 19th February, 2007

at 30 Moffat Street, St Albans, Victoria 3021 from

1a. HAEMOPERICARDIUM

1b, THORACIC AORTIC DISSECTION.

in the following circumstances: !

Mrs Angela Budaj was a 60 year-old female who resided at 30 Moffat Street St Albans, with her

30 year-old son, Branko Budaj.

On the 17th of October 2006, Mrs Budaj consulted with her GP, Dr Nam Duong, when she complained of recurrent lower back pain. She was advised concerning lower back care and exercise and was recommended nurofen analgesic. ‘medication which, according to her GP's

clinical notes, she had supplies of at home.?

On Sunday, the 18th February, Mrs Budaj was unable to move from her couch and appeared to be sweaty. When she attempted to get up from the couch, she was incontinent and also vomited

and her family decided to take her to hospital.

The inquest into the death of Angela Budaj was held at the Coroners Court at Southbank, Melbourne on the Sth

and 6th of February, 2009.

2 See Cinical notes at Page 3 of Exhibit 7.

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Following her arrival at Sunshine hospital, she complained that her pain was increasing, Nursing staff saw her and an initial assessment was undertaken. The records indicate that this assessment ook place at 8.06 pm3 and that Mrs Budaj complained of a sore throat.4

urse Maricar De La Cruz saw her at 9.45 pm. An ‘IV cannulae was inserted and she was given a dose of IV Maxalon 10 mg to stop her dry retching. One litre of normal saline was also given.

arse De La Cruz also tates that Mrs Budaj complained of a sore throat.

An ECG was performed as she was complaining that she felt chest pain when coughing.

She was reviewed by Dr G Young, at 10.10pm and remained under his care until 3.30 am the following morning. His initial record refers to pain on swallowing, as well as lack of oral intake during the day plus vomits x 2 and an episode of incontinence. Her history of hypertension smoking, colecystectomy and abdominal operation with midline wound was noted. At this time her blood test results were available and a provisional diagnosis of infection was made.

Medication was ordered for her sore throat with a chest x-ray and mid stream urine. Normal saline was continued,

Abnormal heart tracing could be seen on the ECG, The ECG results were discussed by her treating doctor, Dr Young, and the Emergency Department Registrar, Dr John Burns,>

"and explained that it was abnormal but.I did not know what to make of it as she had not presented with chest pain or shortness of breath, He agreed with my management plan and did not suggest anything further... He suggested I discuss the case with the night medical registrar ..."6

Dr Young reviewed Mrs Budaj again at 3 am. She said she was feeling much better and was keen to go home. She had walked to the toilet to pass a bowel motion. There was a small amount of urine observed in the catheter bag. When dip sticked the sample showed blood but no leucocytes or nitrates. She told Dr Young, that her throat was much better.

The matter was not discussed with the night registrar and Dr Young stated that he informed Dr Burns of this matter and that it was in these circtimstances that at approximately 4 am she was

3 There was dispute at to time of triage with family members of the view that this occurred at 7pm. It is noted that the nursing staff took a history of diarrhoea, nausea and vomiting since 7 pm, and I accept the medical record as reliable in regard to the matter of time, J cannot exclude the possibility that there may have been some confusion as to the exact nature of Mrs Budaj’s complaint at this assessment.

Mr Budaj and his sister-in-law, Carmen, stated that they believed Mrs Budaj was suffering from a sore neck and they believe nursing staff were informed of this matter, While I do not disbelieve them, the medical record suggests the contrary and I accept that at the time that note was recorded, Nurse McHatten believed that Mrs Budaj, who spoke and understood English well, had indicated that she had a sore throat.

5 Dr Burns was only slightly more experienced than Dr Young. See discussion at transcript page 165-166.

Retrospective notes dated 20/2, page 2 of 2.

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discharged with Dr Burns’ approval, as there did not appear (to Dr Young), to be any infection in her chest or urine. It was suggested that she attend her local doctor the following moming.

On the following morning her son, Branko, arose at approximately 8.00 am and found his mother ying on the floor of her kitchen. She was not breathing and an ambulance was called. She was

aken to Western Hospital, where she was declared deceased at 11am.

t is clear from all of the evidence that Mrs Budaj died of a natural event, which was

haemopericardium following a thoracic aortic dissection, type A.

According to the Director of the Emergency Department, Dr Peter Ritchie,

"Type A aortic dissection is a serious medical emergency with a high mortality rate.

Early treatment can improve the diagnosis. However despite early treatment (early surgery), many patients with this condition still die during or after the surgery and many have other complications, particularly stroke." ~

Dr Ritchie's further opinion was that given her ‘abnormal’ ECG, a cardiology opinion should have been sought and she should have been transferred to another hospital with,

"inpatient coronary care cardiac monitoring facilities ...

...The fact that the patient produced almost no urine during seven and a half hours, despite the insertion of a urinary catheter is also an indication for admission to hospital.

Dr Ritchie also offered that it ‘is difficult to predict what would have happened if decisions had been made on the basis of correct interpretation of the ECG plus or minus

”

the chest X-ray.

And that Mrs Budaj may have been sent to Western Hospital in Footscray for a cardiology opinion and may have undergone further testing and then been transferred to the Royal

Melbourne Hospital for cardiothoracic surgery.

He also opined that had a correct interpretation of her symptoms occurred, her chances of survival

“may have improved."

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He then set out the significant changes wliich have occurred to staffing levels and the training of ED staff doctors since the death of Mrs Budaj at Sunshine Hospital, these dating from February 2008.7

In answer to a question from the Court, Dr Ritchie stated that he thought at the time the x-ray result could not have been downloaded and sent to a radiologist or radiologist consultant for opinion, and that it was

“highly unlikely" that they would come in, ‘if you called them to view a chest x-ray at that time.’8 His further view was that with this presentation Mrs Budaj should have been kept in hospital for further (management) and that her presentation was not addressed by the diagnostic process, which was undertaken.?

Dr Ritchie was further questioned about the notation of chest pain at 8.50pm. He was unable to say whether that matter had been communicated to Dr Young and Dr Burns, (or whether they

were otherwise aware of it). It appears however from the evidence of Nurse McHatten, that the

aking of the ECG,!9

Dr Ritchie was also asked about the comparison of the ECG taken on the 18th of October, and an eatlier ECG available from Medical Records at 8.33 (pm) on the 18th of October. He stated that an orderly would be sent to bring the record to the ED, but could not inform when that occurred in this case.

He further noted that the (18/10) ECG reported stated ‘acute MI’ and stated that, "it needs to be viewed by an experienced doctor."

Dr Ritchies further evidence was that on following his arrival at Sunshine Hospital he reached the view that the staffing levels within the ED were inadequate, particularly over weekends and that there was a need for a more senior registrar, and more senior registrar and consultant ‘cover’ to be available at this time. He then discussed the number of patients secn within the ED over that

See Dr Ritchie’s statement at Exhibit 6, As to the improvements made see also Exhibit 6 (b} and transcript at page 7.

See transcript at page 160 and a discussion of how this system has also now been improved, at transcript page 61.

See (corrected) transcript page 164-165.

See discussion at transcript page 170.

i

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fact of the chest pain was communicated to the medical officer and that was the reason for the -

24 hour period (204), and further stated that the staff levels at that time created stresscs on (inexperienced) doctors to assess patients rapidly which,

“can effect the Doctor’s ability to assess and manage patients because of stress on them, and that time pressure and it's a noisy stressful environment. "11

Dr Ritchies further view was that the process leading to the aortic dissection commenced before or soon after Mrs Budaj arrived in hospital. He further opined that the approach to a cardiologist should have been made over the phone, which: discussion could have been supported by the faxing; of the ECG,12

Dr Ritchie stated,

Type A aortic dissection is a serious medical emergency with a high mortality rate. Karly treatment can improve the diagnosis. However despite early treatment (early surgery) many patients with ihis condition still die during or soon after surgery, and many have other complications, particularly stroke.

It is difficull to predict what might have happened if decisions had been made on the basis of a correct interpretation of the ECG +/-, the chest x-ray. I believe the patient would have been transferred to Western Hospital, Footscray for a cardiology opinion and may have gone for further testing for coronary artery disease and or aortic dissection.

Discovery of the diagnosis then would have required a further transfer to a centre which provides cardiothoracic surgery, such as the Royal Melbourne Hospital, Each transfer exposes the patient to risk. Even if the patient has surgery, there is no guarantee of surviving to hospital discharge or of surviving complication free. However it is possible .

that Mrs Budaj’s chances of survival may have been unproved if a correct interpretation had been made of the abnormal ECG and Chest x-ray and the lack of urine output.

Finding I find that Angela Budaj died at home at some time before 8 am on the 19th of February 2007, and that this followed her premature release from the Sunshine Hospital Emergency Department

by Drs Young and Burns, earlier that morning.

I further find that the presentation of Mrs Budaj was such that her treating doctors should have consulted with a cardiologist, before deciding to release her.

TT See discussion at Transcript 182-185.

!2. See transcript page 188 and 192.

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I also find that the medical management provided in this case was further compromised by the inadequate staffing levels within the Emergency Department, and the high level of workplace

pressure so created.

Finally, while the evidence establishes that appropriate management would have enhanced Mrs Budaj’s chances of survival, it falls short of establishing that the management actually contributed to her death.

In the absence of direct evidence which satisfactorily establishes her chances of survival had appropriate management actually been provided, J return an open finding concerning that matter.

Signature: .

oO -_ C ‘ < A ad Ast Peter While - Coroner a

Date: 10th December, 2010 a

Distribution:

The Family of Angela Budaj.

‘The Chief Executive of Sunshine Hospital.

Dr Burns.

Di Young.

Dr Ritchie.

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