The inquest

In Inquest into the death of Michael James Calder, Deputy State Coroner Lock of the Coroners Court in Queensland considered the circumstances of Mr Calder’s death in the Holy Spirit Northside Private Hospital (hospital) in July 2014. Mr Calder was aged 33 years and had been referred by his GP to the hospital with a three day history of severe occipital headaches, neck pain and stiffness with increasing severity of his headache. He was also noted to be febrile. It was unknown to those treating him at the hospital that Mr Calder had a history of obstructive sleep apnoea.

Whilst in the emergency department, a number of tests were performed and Mr Calder was given analgesia, before being admitted to the ward under the care of a specialist general physician (treating physician).

During the course of his ward admission Mr Calder received analgesia for the ongoing headache including subcutaneous morphine, oxycodone, Ordine (liquid morphine), MS Contin (slow release morphine), Gabapentin (neuropathic pain) along with Paracetemol and ibuprofen.

Over time the doses and dose frequency of opiate analgesia increased for his ongoing pain.

Mr Calder was regularly checked on by nursing staff and there were no obvious signs of narcotisation and when asleep he was breathing normally. Subsequent retrospective reviews of the medical records indicated evidence of deterioration in his respiratory function including low oxygen saturations. Three days after his admission to hospital, Mr Calder was found to be unresponsive and in cardiorespiratory arrest.  He was unable to be resuscitated and was pronounced deceased.

An initial review of the medical records indicated that a probable contributory factor was the level of opiate medication that was being provided to him in hospital. Expert evidence also expressed concern about the prescribing regime of pain medication. The cause of death was found to be due to opiate toxicity.

At inquest, the treating physician acknowledged that his practice and medication regime provided to Mr Calder was wrong. He gave detailed evidence of the treatment history and stated that he genuinely believed he was acting in Mr Calder’s best interests. He also gave evidence of the further self-education he had undertaken and to reflect upon his actions, as well as his now very different approach to acute pain management. He now followed a framework developed following substantial discussion at the hospital’s morbidity and mortality meetings, and which expert evidence also considered was appropriate.

There was also evidence in the inquest that the hospital had conducted a detailed Root Cause Analysis (RCA) which identified a number of system issues and lessons learnt. The Coroner noted the RCA recommendations made and the efforts by the hospital to implement them. The experts who gave evidence agreed the improvements that had been implemented were comprehensive and addressed the issues.

For these reasons, the Coroner did not believe it necessary to make any further recommendations and also did not consider it necessary to refer any hospital staff or the treating physician to any disciplinary bodies.

Take home point

The focus of an inquest is to discover what happened, not to ascribe guilt, attribute blame or apportion liability for a person’s death. However, the coroner may make recommendations about broader issues connected with the death with the aim of preventing similar deaths from occurring in the future. The coroner is also able to refer a matter to the DPP or to a disciplinary body for consideration and possible action.

When preparing for an inquest, it is important to provide the coroner with as much information as possible in relation to any lessons learnt from Root Cause Analysis or any relevant corrective or risk management steps that have taken place since the adverse incident. Both the hospital and treating physician in the Inquest demonstrated insight and were able to give clear evidence to the coroner about the corrective steps they had taken. This averted the need for the coroner to make recommendations and the associated negative publicity that goes with this.