Deceased
Salvatore Accardo
Demographics
47y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2008-03-03
Finding date
2013-01-31
Cause of death
pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm due to Marfan's syndrome
AI-generated summary
Salvatore Accardo, a 47-year-old with previously diagnosed Marfan syndrome, died from pericardial tamponade secondary to ruptured dissecting thoracic aortic aneurysm. He presented to Austin Hospital ED on 22 February 2008 with chest pain, diaphoresis, and weakness, but was misdiagnosed with gastroenteritis. Critical clinical information documenting his cardiac risk factors was documented by paramedics and nursing staff but not incorporated into Dr Rugless's clinical decision-making. While the coroner found no departure from accepted standards warranting adverse findings, she identified the flow of clinical information in the ED as problematic and noted the diagnosis was preventable had aortic dissection been considered. Key lessons: ensure clinically relevant documented information reaches the decision-making clinician; in patients with known predisposing conditions presenting with atypical symptoms, actively seek and integrate information from all available sources; maintain clinical vigilance for rare but catastrophic conditions in appropriate risk groups.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Court Reference: COR 2008 00913
Form 37 Rule 60(1)
Section 67 of the Coroners Act 2008
Inquest into the Death of: Salvatore (Sam) ACCARDO
Delivered On:
Delivered At:
Hearing Dates: | Findings of:
Representation:
Police Coronial Support Unit:
31 January 2013
_Coroners Court of Victoria
Level 11, 222 Exhibition Street Melbourne 3000
8, 9 and 10 February 2012
Coroner Paresa Antoniadis SPANOS
Mr A. E. HILL of Counsel, instructed by Mr L. Kimonides from Slater & Gordon, appeared on behalf of Mrs M.
Mr C. J WINNEKE of Counsel, instructed by Mr R. Perry from Perry Maddocks & Trollope, appeared on behalf of
Mr J. BE. GOETZ of Counsel, instructed by Mr L. Rees from Tresscox, appeared on behalf of Dr W. H. BAIG.
Mr S. P. CASH of Counsel, instructed by Ms Emma Topp,
: ‘DLA Piper, appeared on behalf of AUSTIN HEALTH.
Leading Senior Constable Kelley RAMSEY, assisting the Coroner
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I, PARESA ANTONIADIS SPANOS, Coroner, having investigated the death of SALVATORE ACCARDO and having held an inquest in relation to this death on 8,9 and 10 February 2012 at Melbourne find that the identity of the deceased was SALVATORE ACCARDOborn on 8 May 1960 - _ and that the death occurred on 3 March 2008 _-at 15 Sheridan Way, Roxburgh Park, Victoria 3064 from: 1 (a) PERICARDIAL ‘TAMPONADE 1(b) RUPTURED DISSECTING THORACIC AORTIC ANEURYSM 1(c) MARFAN’S SYNDROME
in the following circumstances:
command of English and was employed at Tibaldi Smallgoods in Coburg as a food handler.
Optithamologist Dr Laurence Sullivan, referred him to Cardiologist Dr George Leitl who
I Paragraphs 1-12 are a summary of facts which were uncontentious, and provide a context for those aspects of clinical . management and care which were contentious and will be discussed in some detail from paragraph 21 onwards.
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diagnosed Marfan’s syndrome, a connective tissue disorder, and commenced treatment with
Atenolol.
However, for at least the ten years immediately preceding his death, Mr Accardo was not reviewed in relation to Marfan’s syndrome either by Dr Leitl, or it appears any other
"cardiologist. He did continue to take Atenolol. as prescribed by a general practitioner.” As recently as August 2006, Mr Accardo underwent treatment for detached retina/s apparently
thought to relate to Marfan’s syndrome.®
4, . At about 1500 hours on Friday 92, February 2008, Mr Accardo became unwell at his workplace and an ambulance was called, Although his heart rate and blood pressure improved somewhat, the ambulance paramedics were concerned about his ongoing chest pain and profuse sweating and called for assistance from a MICA unit at 1526 hours. MICA
paramedics responded and were in attendance from about 1540. They took a handover from
2 Marfan’s syndrome defined in Dorland’s Illustiated Medical Dictionary, 31® edition, page 1862, as “one of the manifestations of abnormal fibrillin metabolism, a congenital disorder of connective tissue characterised by abnormal length of extremities, especially fingers and toes, subluxation of the lens, cardiovascular abnormalities (commonly dilatation of the ascending aorta), and other deformities. It is autosomal dominant disorder with variable degrees of expression, caused by mutations in the FBNJ gene, which encodes fibrillin-1.”
3 Atenolol belongs to the groups of drugs known as beta blockers. It prevents the heart from beating too quickly and is used primarily to treat irregular heart rhythms (arrhythmias), angina, and hypertension (high blood pressure). Atenolol may also be given after a heart attack to protect the heart from suffering further damage. It is marketed in Australia as Anselol, Atehaexal; Genkx Atenolol, Noten Tenormin and Tensig, See New Guide to Medicine & Drugs, The Royal Australian Collegé of General Practitionets; 2008:°.2"
4 Given the remoteness of his clinical management, Dr Leitl was not asked to provide a statement. It is thus unclear if this is an accurate account of what he told Mr Accardo, and if the enlargement of the aorta represented an aneurysm or dilatation of the aorta seen at that time. :
5 Staternent of Mrs Accardo, Exhibit “B’”. Also borne out by the copy medical records provided by Somerton Road Medical Centre which were not tendered in evidence.
§ Documents in the Somerton Road Medical Ceritre file indicate that GP Dr Kathrada, who generally treated Mr Accardo until he left the practice, referred him to Oplithalmologist Dr Laurence Sullivan, who in turn referred him to a Vitreoretinal Specialist Dr William-Campbell. Transcript pages 222,
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the ambulance crew and conveyed Mr Accardo to the Austin Hospital Emergency Department
(ED) arriving at 1607 hours.’
5, Following a verbal handover, Mr-Accardo was triaged at 1620 hours and assigned triage Category 2 - requiring assessment and treatment within ten minutes.’ He was allocated a cubicle at 1623 hours, assessed by Registered Nurse Sarah Jayne Di Santo at 1630 hours, and first reviewed by Dr Mark Rugless, then a Senior Registrar within the ED at 1641 hours. Dr Rugless took a history from Mr Accardo, conducted an examination and reviewed his vital signs which led him to diagnose a presumed gastrointestinal illness. He initiated treatment with Buscopan, an oral Xylocaine viscous/Mylanta mixture, half a tablet of Anginine for ptesumed gastrointestinal colic and possible gastritis and oesophageal spasm form his vomiting, and fluids. Mr Accardo was reviewed by Dr Rugless about one hour later, and
discharged home at about 2020 hours when it appeared he had responded to treatment.”
‘6. According to Mrs Accardo, her husband remained unwell over the weekend and continued to complain..of cramping abdominal pain, not chest pain, but there were no appointments
available at their GP clinic.'©
7, — First thing Monday morning, 25 February 2008, they attended Somerton Road Medical Centre where Mr Accardo was seen by Dr Wirasat Baig in the emergency/treatment room without an
" appointment, as he was'so unwell: Dr Baig was a locum doctor who had not seen Mr Accardo before: He neither documented nor recalled being advised that Mr Accardo had been taken to
the ED by MICA ambulance or otherwise. Based on the history given by Mr Accardo (and to some extent from Mrs Accardo) and his examination, Dr Baig also made a diagnosis of a
gastrointestinal illness which he treated with intramuscular injections Buscopan (an
T Statement of MICA Paramedic Debra Norbury, Exhibit “RE”,
8 See Australasian Triage Scale and Australasian College for Emergency Medicine “Guidelines on the Implementation of the Australasian Scale in Emergency Departments”. Category l=Immediately life-threatening - Immediate simultaneous assessment and treatment. Category 2=Imminently life-threatening/Important time-critical treatment/Very severe pain - Assessment and treatment within 10 minutes (assessment and treatment often simultaneous). Category — 3=Potentially life-threatening/Situational urgency/Severe discomfort or distress — Assessment and treatment start within
30 minutes, and so on. :
_? Statement of RN Di Santo, Exhibit “M™, transcript page. 248.. First statement of Dr Rugless, Exhibit “F’, transcript “ pages'118.and following. : ve 107 note that the GP clinic noted in the medical records is Roxburgh Park Medical Centre (and not Somerton Road Medical Centre) to which a discharge summary would have been sent, if one were prepared. At the time the system in the ED was that the clinician would draft a discharge summary if he/she considered it was warranted. At the date of the inquest, the system in the ED had changed so that a computer-generated discharge summary was routinely sent to the GP nominated by.the patient. Transcript pages 28-34, 167, 169, 178. :
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tenderness”,
antispasmodic) -and Maxolon (an’ antiemetic), and provided a prescription for Maxolon
_ tablets,"!
Mr Accardo returned to see Dr Baig on 26 February 2008. On this occasion, Dr Baig formed the view that Mr Accardo’s gastrointestinal illness was resolving (although he still complained.
of some loose bowel motions) and that he had a new symptoms of right lower back. or flank
pain which he diagnosed as “tumbat sprain?”, specifically documenting “nil renal angle 12 sO
When he returned to the Somerton Road Medical Centre for the third day running on Wednesday_27 February 2008, Mr Accardo was seen by Dr Filomena Lucente. Again,
although she had -been treating Mrs: Accardo for some time, Dr Lucente had not seen Mr Accardo as a patient before that day.'3 Dr Lucente was told of the recent ED presentation and the diagnosis of gastroenteritis, and noted the two previous consultations with Dr Baig as documented in the practice medical records. Following investigations in the practice," and an examination which confirmed right renal angle tenderness, Dr Lucente made a provisional
diagnosis of renal calculus.!> She arranged a CT scan of the urinary tract for that afternoon, to
_ be followed by a teview of Mr Accardo later that day.'®
Mt and Mrs Accardo seturned for a late afternoon consultation with Dr Lucente on 27
February 2008. “As the CT scan report indicated no urinary tract calculus or free abdominal
‘UTM Buscopan.20mg, IM Maxolon 10 mg & Maxolon tablets 10 mg (three times daily). Statement of'Dr Baig, Exhibit
«7 transcript page 197 and following, esp 198, 208-209.
2 Dy Baig’s statement Exhibit “7” and transcript pages 210 and following.
3 Transcript page 221-222,
4 Urinahalysis was positive for blood, ketones and leukacytes. A mid-stream urine sample was also sent for microscopy and cultures, but results would not be known for some few days. Transcript pages 224-229.
15 «Renal calculus” is defined as a concretion occurring in the kidney. If the stone is large enough to block the ureter - and stop the flow of urine from the kidney, it must be removed by either major surgical or radiological fluoroscopy procedures. Mosby’s Medical Nursing & Allied Health Dictionary, 4th edition, page 1348.
16 See generally, statement of Dr Lucente, Exhibit “K”,
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fluid, Dr Lucente made a provisional diagnosis of pylonephritis,’” prescribed antibiotics and
analgesia and arranged an appointment for a further review on 3 March.”®
of fatigue.- He was unable to return to work and spent most of the time resting?
officers who arrived a-short time later.
I do not purport to summarise all the material/evidence, but will refer to it only in such detail
“Pyclonephritis” is defined as a diffuse pyogenic infection of the pelvis and parenchyma of the kidney, Acute pyelonephritis is usually the result of an infection that ascends from the lower urinary tract to the kidney... T) he onset of acute pyelonephritis is rapid, characterised by fever, chills, pain in the flank, nausea and urinary frequency. A urinanalysis reveals the presence of bacteria and white blood cells ... Mosby's, op cit. page 1312.
. 18 statement of Dr Lucente; Exhibit “K™. The inedications prescribed were the antibiotic Keflex (cephalexin) 500mg four times daily for five days, and for analgesia, Panadeine-Forte (500mg paracetamol and 30mg codeine) 1-2 tablets every‘four hours, as required, “ :
19 Statements of Mrs Accatdo, Exhibits “A” and “B”.
207 note that post-mortem toxicological analysis detected Tbuprofen (a non-steroidal antiinflammatory drug marketed in-Australia as Nurofen, Brufen and other names) at a “low” therapeutic level. See paragraph 18 below and the toxicology report in Exhibit “O”, the balance of the brief.
21 Grom the commencement of the Coroners Act 2008 (the Act), that is-1 November 2009, access to documents held by the Coroners Court of Victoria is‘ governed by section 115 of the Act.
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as appears, to me to be warranted by its forensic significance and the interests of narrative
clarity.
. identity of the decéased person, thé cause of death and the circumstances in which death
15,
The purpose of a.coronial ‘investigation of a reportable death? is to ascertain, if possible, the
occurred.” The cause of death refers to the medical cause of death, incorporating where possible the mode or mechanism of death. For coronial purposes, the circumstances in which death occurred refers to the context or background and surrounding citcumstances, but is
confined to those circumstances sufficiently proximate and causally relevant to the death and
not merely all circumstances which might form part of a natrative culminating in death.
The broader purpose of coronial investigations is to contribute to the reduction of the number of preventable deaths through the findings of the investigation and the making of recommendations by coroners, generally referred to as the prevention role> Coroners are also empowered to report to the Attomey-General on a death; to comment on any matter connected with the death they have investigated, including matters of public health or safety
and the administration of justice; and to make recommendations to any Minister or public
the administration of justice.”® These ate effectively the vehicles by which the prevention role.
may be advanced.””
22 The Coroners Act 2008, like its predecessor the Coroners Act 1985, requires certain deaths to be reported to the coroner for investigation. Apart from a jurisdictional nexus with the State of Victoria the definition of a reportable death in section 4 includes deaths that appear “to have been unexpected, unnatural or violent or to have. resulted, directly or indirectly, from accident or injury” and-the death of a person who immediately before death was a patient within the meaning of the Mental Health Act 1986”. : :
33 Section 67(1) of the Coroners Act 2008. All references which follow are to the provisions of this Act, unless otherwise stipulated.
4 This is the effect of the authorities — see for example Harmsworth v The State Coroner [£989] VR 989;, Clancy v _ -West (Unreported 17/08/1994, Supreme Court of Victoria, Harper J.) .
2 The “prevention” role is now explicitly articulated in the Preamble and purposes of the Act of the Coreners Act 1985 where this role was generally accepted as “implicit”. ~ :
26: See sections 72(1), 67 (3) and 72(2) of the Act regarding reports, comments and recommendations respectively.
27 See also sections 731) and 72(5) of the Act which requires publication of coronial findings, comments and recommendations and responses respectively; section 72(3) and (4) which oblige the recipient of a coronial recommendation to respond within three months, specifying a statement of action which has or will be taken in relation to the recommendation. :
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In relation to Mr:Accardo’s death, most of the matters required to be ascertained, if possible,
were uncontentious from the outset, others were clearly uncontentious by the conclusion of the inquest. Mr Accardo’s identity, the date, place and medical cause of death were never at
issue. Lfind, as a matter of formality, that Salvatore Accardo born on 8 May 1960 aged 47,
late of 15 Sheridan Way, Roxburgh Park, Victoria 3064, died at his home in the early houts of 3 March 2008. . 7
Neither was the medical cause of death contentious. Senior Forensic Pathologist Dr Michael Burke from the Victorian Institute of Forensic Medicine (VIFM), performed a full postmortem examination (autopsy), reviewed. the medical deposition and medical records, the - circlimstances as reported by the police to the coroner and post-mortem CT scanning of the whole body. Dr Burke advised that he found an enlarged heart with no evidence of recent or remote infarct; the pericardial sac intact but distended by blood and blood clot; a dissecting thoracic aortic aneurysm extending from the ascending aorta, involving the aortic arch and the entite descending thoracic aorta, with rupture into the pericardial sac, and dissection but no
thrombosis of the carotid atteries.
Toxicological analysis of post-mortem blood, also undertaken at VIFM, revealed no alcohol or other common drugs or poisons, apart from Ibuprofen, a non-steroidal anti-inflammatory drug available in over the counter preparations, at a level of ~2mg/L and Propofol, a short
acting anaesthetic, likely administered .by attending ambulance paramedics. There is no
. suggestion that either drug caused or contributed to death.
Dr Burke concluded. that Mr Accardo’s death resulted from pericardial tamponade,”
secondary to ruptured dissecting thoracic aortic aneurysm due to Marfan’s syndrome and
commented as follows “ «Bostemoriem examination showed pericardial tamponade with
blool distending the pericardial sac. The tamponade has occurred as a consequence of
rupture of a dissecting thoracic aortic aneurysm, The pathological process is well described
28 «Pericardial tamponade” is defined. in Dorland’s, op cit, at page 1893 as acute compression of the heart caused by increased intra-pericardial pressure due to the collection of blood or fluid in the pericardium from rupture of the heart,
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in individuals with Marfan’s syndrome who have a genetic abnormality in connective tissue...There is no evidence to suggest that death was due to anything other than natural
causes,”
I find that the medical cause of Mr Accardo’s death was pericardial tamponade secondary to
“qupturéd digsécting thoracic aortic aneurysm due to Marfan’s syndrome.
The focus of the coronial investigation of Mr Accardo’s death involved the circumstances in which he died, namely the ‘adequacy of the clinical management and cate in the ‘Austin Hospital Emergency Department on 22 February 2008, the related issue of the flow of clinical information within the Emergency Department during Mr Accardo's episode of care, and to a lesser extent, the adequacy of the clinical management and cate provided by Drs Baig and
Lucente on 25 and 26 February 2008, and 27 February 2008 respectively.
Tt should be noted. at this juncture, that Dr Burke’s findings at autopsy were of an extensive
dissection extending from the ascending aorta, involving the aortic arch and the entire - descending thoracic aorta. As I understood the evidence and submissions of the patties at inquest, and certainly with the benefit of hindsight, there is no suggestion that the symptoms and signs of Mr Accardo’s illness represented anything other than the waxing and waning of an uncharacteristically slow, as opposed to acute and catastrophic, dissection.” Tt follows that all three treating clinicians were actually wrong in their diagnoses. However, it does not follow, that the clinical management and care provided by them should be the subject of an
adverse finding or comment, as will be discussed below.”
Debra Norbury was one of the MICA Paramedics who responded to the request from the
attending ambulance crew for MICA back-up/assistance. Her statement and evidence at
inquest was a compilation of what she was told by her colleagues or gleaned, information that
38 Dr Burke’s formal qualifications and experience afé detailed in his seven page autopsy report which is part of Exhibit ”. “(", the balance of the brief.
30 Transcript pages 46,54-56, 73 where Dr Kelly describes the “classic” symptoms of aortic dissection and the significance of Mr Accardo’s changing symptoms over time. This is conceded by Dr Rugless ~ transcript page 164,
3! See paragraph 41 below.
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Mr Accardo had Marfan’s syndrome which she conceded she was probably told ina telephone conversation with Mis Accardo, ‘and-her own observations.” Ms Norbury was aware that Marfan’s syndrome is a connective tissue disorder, and that people who suffer from it have a predisposition to dissection’ She recalled mentioning Marfan’s syndrome to the triage nurse, specifically because Mr Accardo did not look like he had Marfan’s syndrome and she said so
at the time.”
24, -Apart-from a'verbal handover to the triage nurse in the ED, Ms Norbury compiled ‘a “Patient Care Report” while she was still in the ED, and a printed “hospital” copy of that report time stamped 1649 hours which is within the medical records.*> The report includes the following information which, if considered, raised the possibility of an aortic dissection and/or belied a diagnosis of simple gastroenteritis - under final assessment “acute myocardial infarction?
acute coronary. syndrome? thoracié. aneurysm?”; under patient complaint “pain >> squeezing chest pain”; under past history “heart valve problem diagnosed approx 10 yr ago and ? hypertension, Marfan’s syndrome? Meds Tenormin”; under case nature “cardiovascular problem”; case description “Pt at work today when had sudden onset of right leg weakness and became extremely sweaty. Sat down and MAS called. Greenvale crew arrived found Pt to be diaphoretic, had squeezing central chest pain HR 50 and unrecordable BP (later found BP only reading left arm) autoinfused Pt, gave aspirin and gained IV access 18g right dorsum”; under secondary survey “nain>>central chest squeezing, rates as
moderate; sweating: >>no radial pulse right arm; denied nausea; short of breath”*®
The triage form documents a series of vital signs taken at triage and the following under
32 Statement of Debra Norbury, Exhibit “B” and transcript pages 96 and following generally.
38 Transcript page 977, i
34 Transcript pages 101-102. Mr Accardo was 179 tall and weighed 85 kg (see page j of the autopsy report in Exhibit “Q”) whereas people with Marfan’s syndrome usually have a lanky appearance with long limbs and extremities. See footnote 2 above. .
AS page VACIS-electronic Patient Care Report — see the medical records in Exhibit “O” balance of the brief,
34 "The report also documents that Aspirin 300mg was given orally by the Greenvale crew before handover to the MICA crew who administered Morphine 3mg LV. with effect @ 1548; GTN patch @ 1555: Morphine 3mg IV with effect @ 1557;GTN sublingual with no effect noted @ 1600; Morphine 4mg IV with effect @ 1605 before arrival at the ED at
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arm but good capillary refill and colour...
“triage assessment” ~ Right leg weakness, diaphoretic, chest pain, no radial pulse in right arm, aspirin morphine 10mg, GIN patch (presumable by way of summary of pre-hospital
treatment).
The bottom half of the triage form contains a “cubicle assessment” made by RN Di Santo shortly before her first documented set of observations at 1630. RN Di Santo also received a verbal handover from the MICA Paramedics and the cubicle assessment is an amalgam of this and her own assessment of Mr Accardo, RN Di Santo’s cubicle assessment includes the following — under history of presenting complaint “Patient was at work. Complained of right
sided leg weakness. Diaphoretic 44 and complained of chest pain. Nil radial pulse to right
The evidence at inquest supports a finding that when Dr Mark Rugless first assessed Mr Accatdo at 1641 hours, neither RN Di Santo, nor Mrs Accardo were present.” According to
his handwritten entry in the medical record, which he interpreted at inquest, he was aware of
“the diagnosis of Marfan’s syndrome and that Mr Accaido took Atenolol, which he considered
a faitly standard medication for patients with the condition.”
The history of presenting complaint which Dr Rugless obtained directly from Mr Accardo,
‘and on which the diagnosis ofa gastrointestinal illness was based, was of “Cramping
abdominal pains, last four hours, nausea ++, feels bloated, vomited twice in the ED, diarrhoea ++, no chest or back pain, no shortness of breath, no fevers or sweats.” Despite apparently not eliciting a history which raised the possibility of a dissection, or the need to exclude a dissection, and being unaware of Mr Accardo’s recent complaints of chest pain, Dr Rugless specifically asked about chest or back pain by way of general screening questions,
and-Mr Accardo denied having these symptoms.”
38 Hor convenience, I have interpreted the abbreviations used in the actual document.
39 Note that the “‘off-stretcher” according ta the Ambulance “Patient Caré Record” was 1623 hours, that is the time the patient was transferred from the ambulance stretcher to the bed in the assigned cubicle. RN Di Santo agreed in ..
evidence that the cubicle assessment was made by her at about the time of the verbal handover. Exhibit “M” and transcript page 243 and following, esp 246,259.
"4 Transoript pages 108, 118, 252-253.
® Transcript pages 118-119.
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At inquest, Dr Rigless was questioned about his réliance on the history he obtained from Mr Accatdo, rather than investigating other sources of information, such as ambulance, triage and even nursing notes, or collateral history from family members, He maintained that it was a general practice, consistent with his formal training and experience, where a patient is able to give a clear and coherent history; to rely on that as his primary source of information, and to seek other information ‘or collateral history, only if the patient is confused or disorientated, or unable to give a history for some other reason.* It appeared that his stance in so doing relied in part on the practical realities of practice within a busy ED setting, in which the time to corroborate a history from an able patient/historian was a luxury. In terms of weight which might be attached to other sources of information, he considered the cubicle history and assessment history more definitive: than that obtained by ambulance officers, which was generally obtained in more chaotic circumstances, and saw triage as being fundamentally
about prioritisation of patients, and not diagnosis.”
Although initially unclear, the weight of the evidence before me supports a finding that the Triage Form/Cubicle Assessment sheet and the sheet on which Mr Accardo’s vital signs and
nursing notes were made by RN Di Santo were stapled together during his episode of care in the ‘Ep.6 Dr Rugless testified that while he would refer to the patient’s vital observations as recorded by nursing staff, he would not generally pay any attention to the nursing notes which are made in the right hand margin of the same sheet of paper”” The combined effect of these two pieces of evidence is that, at; one ‘or other review of Mr Accardo, Dr Rugless had. in his hand all the information which would-have led him to investigate for ot exclude the possibility
of an aortic dissection had he chosen to read it
Emergency Physician Dr Anne-Maree Kelly was nominated by the Australasian College for
Emergency. Medicine (ACEM)” to provide the court with an independent assessment of the
“Transcript page 120, 126, 128, 130, 139, 150, 153.
46 ‘Transcript pages 191-192, 259, 263; 271-2.
© Transcript page 157 and following. See also statements of Dr Kelly, Exhibits “C” and “D” and transcript pages 25
4 Australasian College for Emergency Medicine is an incorporated educational institution whose prime objective is the : _ training and education of specialist emergency physicians.
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clinical management and care provided to Mr Accardo.’ Dr Kelly provided a generalist’ s understanding of Marfan’s syndrome and described aortic dissection as a well-known but not
inevitable complications of the condition.” As to the frequency of aortic dissection, Dr Kelly
_desctibed ‘it as a rare condition with some 20-40 cases occurring annually within the Victorian
population of 4 million people, not all of which arose from Marfan’s syndrome, and only about half of which would. even make it to hospital. Another way of looking at the rarity of the condition, is to consider some 20 presentations of aortic dissection annually, in the context
of some 1,5 million presentations to hospital EDs annually.°*
“Dr Kelly identified those symptoms and signs in Mr Accatdo’s presentation which were
documented in the medical records and which pointed to the possibility of an aortic dissection including the combination of truncal pain and weakness in a limb, classically chest pain and a neurological feature, either chest or back pain, very localised back pain described as ripping,
numbness or tingling in the limbs, heart rate changes both up and down. Dr Kelly was clearly
‘of the opinion that if the vatious symptoms and signs documented by the ambulance officer,
the triage nurse and the cubicle nurse, had been brought to Dr Rugless’ attention, he would
have investigated Mr Accardo for an aortic dissection and/or made the diagnosis.
She also identified the problematic flow of information within EDs as a systems issue fundamentally, and not an issue of the clinician’s competence - a systems issue which spoke
to the disparate way information was recorded. within EDs, and to a lack of integration so that
_ ambulance notes, and even triage and cubicle assessments, may not be available to a clinician
during the whole of a patient’s episode of care®* Unfortunately, Dr Kelly gave evidence. at the inquest before those witnesses who clarified the availability of the ambulance Patient Care Record from. 1649 fiours and the combined triage/cubicle assessment and vital signs/nursing
notes were available shortly before 1630hours, and before Dr Rugless clarified that he would
Dr Kelly provided two reports — one dated 16 April 2011 primarily concetned with the ED presentation and the other dated 4 January 2012 concerned with the GP consultations, They were Exhibits “C” and “D” respectively.
Transcript pages 44.
2 Transcript pages 45and following.
_ 3 Transcript at pages 58, 64-65, 70. .
“4 Transcript page 47 and following.
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not even look for other sources of information unless he perceived a problem with the history .
the patient had given him.”
Nevertheless, Dr Kelly condoned this approach, testified that Dr Rugless’ clinical assessment
and treatment of Mr Accardo was appropriate “based on the clinical information elicited from
Mr Accardo”, %5 stressed:that clinicians should always take as detailed and complete a history
as possible,” and reflected on the realities of ED practice in the following terms —
“That said though, in optimal circumstances, safety is highest if we use information from every source that we can possibly get it. Unfortunately, in our hospital systems, the sources of information are not integrated in,a way that makes that at all easy. So the ambulance staff diligenily fill in their paperwork but its timing of arrival and where it’s put, is not always congruent with when the doctor is seeing the patient or where the doctor’s stuff is kept and similarly, the nursing notes may not be complete — the triage note may not have been completed before either and is not necessarily kept in the same place. .Emergency Departments are very busy places, So you don’t actually have the luxury of chasing everything for everybody all the time ... So in most people’s practice, and certainly in my practice, if we can get a really good story from the patient themselves, they are the best source
of information ... Corroborating evidence from family members and people who are present is
also useful. If for any reason we — the story doesn’t add up or they’re unable to give a clear
story, then we would go chasing imoré information, which would include...chasing the ambulance.form if it’s not inmediately available...it actually has to be on a selective basis, because we just don’t have the time to do it.”
Dr Kelly maintained that emergency medicine is best practiced in a “team? environment and placed some. responsibility on any nutse who becomes aware of a discrepancy between their history and/or. assessment of the patient and the doctot’s history, diagnosis and/or treatment to
draw the discrepancy to the doctor’s attention. This presupposes that the nurse appreciates
56 Exhibit “C” and transcript pages 48, 57-58.
51 Tyanscript pages 52-53, 57-58, 64 58 Transcript page 49. See also transcript page 60.
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37,
that there is a discrepancy, and that the culture of the particular ED supports him/her to do so
or, alternatively, provides escalation pathways through senior nurse clinicians or otherwise.”
As regards the “culture” of the ED, Dr Fergus Kerr, Director of Emergency Medicine at Austin Health, testified that they aim for a flat non-hierarchical structure and encourage nurses
to raise issues of concern with doctors, as well as providing escalation pathways. He agreed
-with Dr Kelly about placing some responsibility on the cubicle nurse to alert the clinician to
any perceived discrepancy; but with reservations. He thought it-all tumed on timing, and that if the nurse was not present when the doctor was taking a history or before he/she had formulated a diagnosis, it would be fairly challenging for a jutior nurse to appear to gainsay
the doctor.
In her evidence at-inquest, RN Di Santo echoed Dr Kert’s reservations. In the first place, she was unaware of Marfan’s syndrome and its clinical significance. Moreover, she testified that she would not have perceived any inconsistent history or discrepancy. RN Di Santo assumed
that Dr Rugless would obtain a history from the patient himself, and “get the whole story
whether by looking at the notes or asking me”, She felt it could be daunting to question a
"doctor but would do so if she felt concerned for a patient. 61 RN Di Santo assumed that the
doctor would always read ‘the’ triage notes, In her own history taking, she testified that she would go to other sources of information if her patient was a vague historian. Although she had no specific recollection of Mr Accardo’s presentation on 22 February 2008 and was giving evidence relying largely on the nursing notes she made in the medical record, RN Di
Santo noted that she had doctimented that Mr Accardo was alert and orientated, in her
. assessment.”
Ms Janice Brown was the Nurse Unit Manager of the Austin ED, and a nurse with 30 years experience, 27 years of which were within an ED setting. NUM Brown agreed with Dr Kerr’s gloss on Dr Kelly’ s opinion that emergency medicine is best practiced in a team where
team members shoiild feel empowered to speak up where they perceive a discrepancy or have
~ goncetns about clinical ‘management. That is, she felt that it would depend very much on
3° Bxhibits “C’ and “D” and transcript pages 52, 64 and following.
© Transcript page 179 —I think this is the gist of his evidence, although paraphrased. See also transcript page 181-182.
Sho Transctipt pages 253-257, 262-263.
a Transcript page 258.
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whether the nurse had the requisite clinical experience to perceive the discrepancy in the first place. NUM Brown felt that RN Di Santo would have been operating at the level of an inexperienced albeit fully qualified emergency nurse at the time. Based on her lengthy experience, she testified that emergency physicians do not always consult ambulance or triage notes, and that it was common practice for them to refer only to their documented vital signs,
but not their nursing notes and broader observations.”
39,
On one reading of Dt Kelly’s second report, a criticism of the clinical management and care
provided by Drs Baig and Lucente was implied. 6 At inquest, she clarified that in her opinion _
Mr Accardo’s presentations to the GPs were missed opportunities, in the theoretical sense, for a correct diagnosis to be made in time to change the outcome for Mr Accardo. She was not critical of the doctors for. their management plans, based as they were, on the histories they
elicited from Mr Accardo. Indeed, Dr Kelly testified that she would have been astounded if
either doctor had made the diagnosis of aortic dissection on the information available to them
at the time.®° She did, however, maintain that there were some “soft signs” which pointed to the possibility of aortic dissection and/or of a more serious underlying cause for Mr Accatdo’s symptoms, as well as the fact of multiple presentations within a few days which could have
raised concerns, in and of itself, oF
There were a number of discrepancies between Mrs Accardo’s recollection of her husband’s attendance on the two doctors, which I do not propose to resolve, in the citcumstances, save to say that in respect of the attendance on 26 February 2008, Dr Baig’s statement does not sit
comfortably with the clinical notes he made at the time. Even if Mrs Accardo’s tecollection
~,of what transpired on these occasions,is accurate, there is no evidence that either he or Dr
Lucente were ever appraised of a history that encompassed the early, telling symptoms and signs Mr Accardo had on 22 February 2008, which might have pointed the doctors towards
the correct diagnosis.
Transcript page 269.
& Transcript pages 270-271.
§ Bxhibit “D”.
6 Transcript pages 73, 78, 83, 86.
© Transcript pages 76, 78, 80, 81, 85, 91, 92, 93.
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Al. The standard of proof for coronial findings of fact is the civil standard of proof on the balance
of probabilities with the Briginshaw gloss or explication. The effect of the authorities is that Coroners should not make adverse findings against or cormments about individuals or institutions involved in the clinical ‘management or care of the deceased, unless the evidence provides a comfortable level of satisfaction that their negligence and/or departure from the
generally accepted standards of their profession caused or contributed to the death.
dissection during that episode of care, caused or contributed to his death some ten days later.”
43, However, the weight of the evidence before me does not support an adverse finding against either Dr Rugless ot Austin Health, as his approach does not appear to have departed from the generally ‘accepted standards of his profession, and the flow of information of clinical significance in the ED, although problematic, does not appear to be any more so than in other
Emergency Departments in tertiary hospitals in the State. This is not an edifying conclusion.
"presumed gastrointestinal illness.
45, Similarly, there is no basis in the evidence before me to make any adverse finding or comment
against either Dr Baig or Dr Lucente.
§§ Briginshaw v Briginshaw (1 938) 60 C.L.R. 336 esp at 362- 363 - “The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding, are considerations which must affect the answer to the question whether the issues had been proved to the reasonable satisfaction of the tribunal. In such matters “reasonable satisfaction” should not be produced by inexact proofs, indefinite testimony, or indirect inferences...
§ Anderson v Blashki [1993] 2 VR 89 at 95; Secretary: to. the Department of Health & Community Service v Gurvich [1995] 2-VR 69 at'73-74; Re State Coroner; :ex parte Minister for Health (2009) 261 ALR 152 at [21]
® Transcript pages 73, 78.
7 Transcript page 73.
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» 46.
That said, it is a sorry state of affairs, when clinically relevant information which finds its way into the medical records, is not-factored into clinical decision-making at its most crucial. At the risk of appearing glib, it is of little comfort to the family that the coronial investigation
brings to light matters which were known at the time, were properly documented and
clinically significant, but were either not accessible, or not accessed by the treating clinician.
The evidence before me supports a finding that correct diagnosis of Mr Accardo’s illness was
. confounded by his atypical presentation of a rare condition, the varying symptoms and signs
-over the. course of his illness, and thé’ absence in any version of the history elicited from him,
of his diagnosis over ten years earlier of an “enlarged aorta’, which might of itself have
prompted further investigation.
Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected
with the death:
I was advised during the, course of this investigation of a number of initiatives at Austin
"Health “which were ‘relevant to ‘the éircunistances of Mr Accardo’s death, which should
improve patient safety in the future and which should accordingly be acknowledged -
e The promulgation in February 2009 of an AAA/Aortic Dissection” Guideline for the Emergency Department ‘under the hand of Dr Kerr.as Director of Emergency Medicine, which includes, inter alia, a requirement that patients suspected of having either condition should be triaged Category 2 and the triage nurse must inform the ED
consultant/senior registrar and the vascular registrat/fellow.
e A document entitled “Responsibilities at the Austin Hospital” setting out paramedic responsibilities and corresponding Austin Hospital staff responsibilities which includes articulates the requirement that paramedics compete the electronic Patient Care Record in a timely manner and place the printed report in the patients record slot/adjacent to’
the cubicle.
7 AAA tefers to abdominal aortic arieurysm ~ a ‘condition which poses similar clinical challenges as thoracic aortic dissection | or aneurysm. :
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‘se Ongoing review of triage within the ED, including the involvement of senior doctors at the triage stage, in part to ensure that important clinical information conveyed in the
verbal handover, is not lost.
that the normal pressures of ED practice militate against a clinician actively incorporating clinical information from all reasonably accessible sources, patients like Mr Accardo, who may not be the best historians in their own cause, are at risk. Dr Kelly spoke of clinicians making diagnoses based on a snapshot of the movie which is the course of an illness. To pursue this metaphor, several snapshots, even if taken by health professionals from different
disciplines, are likely to enhance the clinician’s view of the patient.
Austin Health .
Dr Mark Rugless Dr Wirasat Baig Dr Filomena Lucente Dr Ann-Marie Kelly
Australasian College for Emergency Medicine
Signature:
PARESA ANTONIADIS SPANOS CORONER Date: 31 January 2013 cn
3 Transcript page 85.
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