Finding into death of Warren Douglas Frazer

Contributing factors

• Tumour invasion of T6 vertebral body not detected on pre-operative imaging
• Intraoperative discovery of vertebral body invasion requiring difficult surgical decision
• 8-hour delay from recognition of spinal cord compression to laminectomy
• Post-operative epidural haematoma causing spinal cord compression
• Tracheopleural fistula development post-decortication
• Recurrent fistula despite multiple surgical repairs
• Aerocephalus (air in cerebrospinal fluid) from fistula communication with subarachnoid space
• Lack of intraoperative neurosurgical support at primary hospital
• Informal inter-hospital transfer arrangement delaying definitive neurosurgical management

Coroner's recommendations

1. The Northern Hospital implement a formal policy describing how family members and next of kin are to be kept informed about surgery progress, particularly when surgery takes longer than estimated.
2. The Northern Hospital formalise arrangements for transferring patients to St.Vincent's Hospital or The Austin Hospital and document those arrangements in a protocol agreed upon by the hospitals.
3. The Northern Hospital audit compliance with the Cancer Optimal Care Pathway in relation to peri-operative investigations and planning.
4. The Northern Hospital audit the effectiveness of the Head of Thoracic Surgery and newly appointed full-time Thoracic Surgeon in providing timely assistance and support to thoracic and other surgeons.