A New South Wales Coroner has recommended that the Health Care Complaints Commissioner (HCCC) investigate the care and treatment a doctor provided to an Oaklands man in November and December 2019 as an inquest into his death concluded.
Deputy State Coroner Erin Kennedy's recommendation notes that "the brief of evidence, transcript of evidence given at the inquest, and a copy of the [inquest] findings" be forwarded to the HCCC, and that it should consider "whether any disciplinary action is required".
The coronial inquest was looking into the death of 79-year-old William Edmunds who died in the intensive care unit at Albury Base Hospital on December 2, 2019, from complications of peritonitis.
One of the contributing factors was found to be a failed bowel operation performed on him on November 7, 2019.
That operation, a Hartmann's procedure, was performed by Dr Liu-Ming Schmidt and involved removing a large piece of Mr Edmunds' bowel.
Dr Schmidt performed it on the wrong end of Mr Edmunds' colon though — the distal end.
The coronial inquest concluded last month with Ms Kennedy finding that other contributing causes to Mr Edmunds' physical decline and death included prolonged delays in diagnosis of a mechanical bowel obstruction, together with underlying natural causes.
The HCCC has been contacted for comment.
Disclosure recommendations
This week, Ms Kennedy's inquest recommendations were publicly released on the New South Wales Coroners Court website with four of them handed down at the conclusion of proceedings.
Besides the HCCC recommendation, the coroner noted that the executive of Albury Wodonga Health should consider "implementing a surgical audit tool to facilitate the capture and recording of data in real time in respect of surgical outcome".
During the inquest a number of doctors raised concerns about matters regarding Mr Edmunds' care including increasing levels of fentanyl for his pain relief following the failed operation and the time taken to request an abdominal CT scan after that.
The other two recommendations were also made to the executive of Albury Wodonga Health, as well as the Australian Commission on Safety and Quality in Health Care (ACSQHC).
One of them noted that "consideration be given to the implementation of a policy, or promulgation of a directive, that mandates the presence of a witness at the initial disclosure of a medical complication where the disclosure is made by the health practitioner who made the error".
"The witness would be equal to, or more senior than, the practitioner who made the error," the coroner's note said.
The other recommendation concerned considering implementing a policy or directive that requires, where practical, to inform a patient who has experienced an avoidable medical error that they may request that the health practitioner who made the error no longer be involved in their care.
Albury Wodonga Health and the ACSQHC have been contacted for comment.
Patient's perspective crucial, coroner says
The inquest heard concerns from Mr Edmunds' children Wade and Susan, as well as nurses involved in his care, that Dr Schmidt had not communicated properly to Mr Edmunds and the family about the failed Hartmann's procedure in a process called "open disclosure".
It also heard from the family and their legal representative Kate Williams that there should have been an option for Mr Edmunds and his family to request that a different doctor attend to him.
While doctors said throughout the inquest that it was important Dr Schmidt continue providing care to Mr Edmunds, and that she had an obligation to attend to her patient, Ms Kennedy noted that the patient's perspective was crucial.
"The choice and consent should remain with the patient to accept that surgeon as the continuing surgeon or to change surgeons," the coroner noted.
"The evidence from the doctors was generally a surgeon would be present at the rectification surgery if not conducting it.
"In most cases it would be reasonable to have the surgeon repair the error, but surely this must always be the decision of the patient after open disclosure.
"In this matter Mr Edmunds was too unwell to advocate for himself, and his family would have done so if given the opportunity and choice, which they were not."
Dr Schmidt apologised to Wade and Susan several times throughout the inquest and admitted that she was "out of her depth" following the failed bowel operation.
