Inquest into the death of Patrick THOMAS

Contributing factors

• Accidental division of superior mesenteric vein during laparoscopic colectomy
• Tumour distortion of normal vascular anatomy
• Failure to report death to Coroner despite meeting reportable death criteria
• Incorrect death certification without coronial notification
• Absence of Root Cause Analysis at either hospital
• Lack of inter-hospital communication protocols between private and public facilities
• No formal notification process between hospitals when patient transferred for escalated care
• Surgeon's misunderstanding of coronial reporting obligations
• Closure of Kareena Private Hospital records before patient outcome known
• Inadequate surgical documentation of the complication

Coroner's recommendations

1. That where a patient transferred for care from a private health facility dies in Sutherland Hospital, there be a written protocol providing for: (a) notification of the death to the Director of Clinical Services/General Manager of the private health facility from which the patient was transferred; (b) notification by the Director of Clinical Services at Sutherland Hospital to the LHD Director of Clinical Governance for consideration of action under the NSW Health 'Incident Management Policy'
2. That where a patient transferred for care from a public health facility dies in Kareena Private Hospital, there be a written protocol providing for: (a) notification of the death to the General Manager/Chief Executive of the public health facility from which the patient was transferred; (b) communication between the Director of Clinical Services of Kareena Private Hospital and Director of Clinical Services of the public health facility as to whether follow up review is required, who is responsible and what resources should be shared
3. Where a transfer for escalated care follows surgery, the surgeon must complete and sign a transfer document, outlining the nature of the operation, the complication (if any) and reasons for transfer
4. That Kareena Private Hospital implement training and education regarding the requirement of a Root Cause Analysis be conducted
5. That Kareena Private Hospital implement training and education regarding the requirement to notify a Coroner of a death