Finding into death of Paschaliny Berias

FORM 38 Rule 60(2)

FINDING INTO DEATH WITHOUT INQUEST

Section 67 of the Coroners Act 2008 Court reference: 782/08 In the Coroners Court of Victoria at Melbourne J, AUDREY JAMIESON, Coroner having investigated the death of: Details of deceased: Surname: BERIAS Firstname: PASCHALINY Address: AVONDALE HEIGHTS, VICTORIA 3034 without holding an inquest: find that the identity of the deceased was PASCHALINY BERIAS and death occurred on 24 February 2008 at Western General Hospital, 160 Gordon Street, Footscray, Victoria 3011

from: la. GALL STONE ILEUS - SMALL BOWEL OBSTRUCTION

Pursuant to Section 67(2) of the Coroners Act 2008, an inquest into the death was not held and the deceased was not immediately before the person died, a person placed in custody or care; but there‘is a public interest to be served in making findings regarding the following circumstances:

1. Mrs Paschaliny Berias was born on 25 March 1923, She was 84 years old at the time of her death. Mrs Berias had a medical history of hypertension, Type II diabetes, chronic renal failure and a recent diagnosis of dementia, ,

2. On 20 February 2008, Mrs Berias was seen in the Emergency Department (ED) at Western Hospital with peri-umbilical pain and diarrhoea. Investigations at the time showed faccal loading

on abdominal X-ray but no obvious evidence of obstruction. She was treated conservatively.

3. On 22 February 2008, Mrs Berias presented again to ED at Western Hospital with similar problems and was again treated conservatively with fluids and an enema.

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4, On the evening of 23 February 2008, or in the early hours of 24 February 2008, she complained of feeling unwell. Her son, Mr Nick Berias, was taking her back to hospital when she vomited and collapsed, On presentation to the ED at Western Hospital at 02.00am, she was in asystole. She was intubated and cardio-pulmonary resuscitation was implemented.

5. During resuscitation attempts, Mrs Berias vomited copious amounts of bile stamed fluid.

Resuscitation attempts continued until approximately 4.35am at which ime Mrs Berias was declared deceased.

6. The cause of Mrs Berias’ death was not apparent to the medical practitioners at the Western Hospital. A medical deposition gave no opinion as to the cause of death and, death was not expected,

7. An autopsy was performed by Dr Paul Bedford, Forensic Pathologist at Victorian Institute of Forensic Medicine, after an external examination and a post mortem CT scan failed to identify a cause of death. Dr Bedford's post mortem findings were of a small bowel obstruction due to gallstone ileus, Dr Bedford commented that the small bowel obstruction with resultant vomiting results in loss of fluids and metabolic disturbances, ;

8. The Clinical Liaison Services (CLS)! reviewed the medical management of Mrs Berias at the request of the coroner.

9, A statement was obtained from Dr Michael Bryant, Director of Department of Emergency Medicine, Western Hospital, Footscray. Dr Bryant’s report set out details of Mrs Berias’ presentations at the ED noting that on both the 20 February and 22 February 2008, investigation of her complaints were performed and bowel sounds were noted to be present on both occasions.

On both occasions she was discharged after improvement had been noted and with a letter to provide to her local doctor.

10. Dr Bryant acknowledged in his statement that the hospital did not have guidelines for the assessment and management of elderly patients with abdominal pain although doctors coming to work in the ED are provided with a handbook for orientation purposes. Dr Bryant also provided information that a HMO saw Mrs Berias on her first attendance at ED and an intern on her

1 ne role of the CLS is to assist the Coroner’s investigation into the nature and extent of deaths which occurred

during the provision of healthcare, and identify potential system factors in healthcare related deaths, CLS personnel

comprise of practising Physicians and Clinical Research Nurses who draw on their medical, nursing and research

experiences, skills and knowledge to independently evaluate clinical evidence for the investigation of reportable

healthcare deaths and to assist in identifying remediable factors that may assist in prevention and risk management -in health services settings. .

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second attendance. On the second attendance the Emergency Department was short staffed with only one consultant on duty instead of the usual two, however, the intern at the time did not identify any significant change in Mrs Berias’ pathology from her first presentation that suggested to her that she should discuss Mrs Berias with a more senior doctor.

11. The CLS reported to the coroner that they were unable to identify any guidelines for the assessment and management of elderly patients with abdominal pain on either the Department of Human Services website or the Australasian College of Emergency Medicine website.

12. According to an article entitled ‘Abdominal Pain in Elderly Persons’ by E David Bryan, MD, Assistant Professor of Emergency Medicine, Texas Tech University Health Science Centre? "the evaluation of elderly patients presenting with abdominal pain poses a difficult challenge for the American physician." Dr Bryan identified a number of factors including pre-existing conditions of which can influence initial diagnosis with benign conditions such as gastroenteritis or

• constipation, Dr Bryan indicates that this is an increasing problem in part because of the increasing elderly population.

13. This article sets out an extensive guide for medical examinations in the emergency departments. ,

COMMENTS:

Pursuant to Section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:

1. A review of the medical management of Mrs Berias indicates that reasonable and appropriate attention and investigations were performed in response to her clinical presentation. There were no overt clinical features to suggest the diagnosis of a small bowel obstruction should have indicated to the medical practitioners involved in her care that either further investigations were warranted or that a more senior member of staff should be consulted.

2. At the same time, the investigation has highlighted that there is an absence of specific guidelines for the assessment and management of elderly patients presenting with abdominal pain to the emergency department. Such guidance could provide an important diagnostic aid particularly to more junior doctors,

3, The investigation has also highlighted that despite Mrs Berias’ representation to the ED within 48 hours there was no escalation of the level of experience of the doctor allocated to examine her.

2 This has been accessed from E-Medicine dated 5 November 2008

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RECOMMENDATIONS:

Pursuant to Section 72(2) of the Coroners Act 2008, I make the following recommendation(s) connected with the death:

1. The Department of Human Services and the Australasian College of Emergency Medicine work in conjunction to develop guidelines for the assessment and management of elderly patients with abdominal pain presenting to the emergency department,

2, That the Department of Human Services and the Australasian College of Emergency Medicine consider including as part of the management guidelines, the automatic escalation to a more senior clinician in circumstances where patients present on a sccond occasion with the same/similar symptoms such as demonstrated in Mrs Berias’ case.

FINDING:

1. .T accept and adopt the medical cause of death as identified by Dr Paul Bedford and find that

Paschaliny Berias died from a small bowel obstruction due to gallstone ileus.

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Signature:

AUDREY JAMIESON CORONER —

21 April 2010

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