Coronial
WAhospital

Inquest into the Death of Fox

Deceased

Kenneth Charles FOX

Demographics

62y, male

Date of death

2006-04-13

Finding date

2009-02-01

Cause of death

Acute Gastrointestinal Haemorrhage in association with Acute on Chronic Peptic Ulceration

AI-generated summary

Kenneth Charles Fox, 62, presented to Fremantle Hospital ED on 12 April 2006 with a gastrointestinal bleed after fainting. He was diagnosed with a massive bleed causing hypovolaemic shock and stabilized with fluid resuscitation. However, due to difficulty determining whether the bleed was upper or lower GI, and the assumption among registrars that investigation could wait until morning, no urgent endoscopy was arranged overnight. He deteriorated around 08:00 hours on 13 April 2006 and became haemodynamically unstable. Attempts to locate an available gastroenterologist or surgeon for emergency endoscopy failed due to staff being committed to other procedures or off-site. He suffered cardiac arrest at 10:36 hours and died. Postmortem revealed a large peptic ulcer in the duodenum. The coroner found that had endoscopy been performed around 08:00 hours on 13 April, the ulcer could likely have been treated to prevent massive haemorrhage and death. Key systemic issues included lack of dedicated emergency surgical cover during business hours and inadequate endoscopy facilities. Since 2008, Fremantle Hospital implemented a General Surgeons Agreement to ensure dedicated day surgeon availability.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicinegeneral surgerygastroenterologyintensive caregeneral medicine

Error types

diagnosticdelaysystemcommunication

Drugs involved

aspirinibuprofenpacked red blood cellsproton pump inhibitor

Clinical conditions

acute gastrointestinal haemorrhagepeptic ulcer diseaseduodenal ulcerhypovolaemic shockhaematemesismelaenahaematocheziaanaemiatachycardiacoagulopathy

Procedures

endoscopygastroscopyfluid resuscitationblood transfusion

Contributing factors

  • Failure to arrange urgent endoscopy overnight despite diagnosis of massive GI bleed with hypovolaemic shock
  • Diagnostic uncertainty regarding upper versus lower GI bleed source
  • Assumption by registrars that investigation could be deferred until morning
  • Lack of dedicated emergency surgical cover during business hours (08:00-18:00)
  • Unavailability of gastroenterologist or surgeon to perform emergency endoscopy at time of second bleed
  • Self-medication with large quantities of aspirin and ibuprofen not initially disclosed or proactively enquired about
  • Inadequate endoscopy facilities (small procedure rooms without proper anaesthetic and resuscitative support)
  • No consultation with on-call consultants during night shift to prioritize urgent investigation
  • Registrars did not convey urgency of diagnosis prior to further bleed

Coroner's recommendations

  1. The proposed Fremantle Hospital expansions (extended ICU with High Dependency Gastrointestinal Unit) should be excluded from current budgetary cut-back requirements. These expansions were viewed by all consultant doctors as necessary to prevent outcomes like the deceased's by providing: (1) a dedicated theatre in close proximity to intensive care or high dependency unit for emergency endoscopy with provision for laparotomy if needed, (2) proper anaesthetic and resuscitative support, (3) when combined with the Day Surgeon Agreement and dedicated theatre, this would enable emergency endoscopy to be performed rapidly with surgical intervention available if required.
Full text
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