The Background
Virginia Weekes was a 70-year-old woman who died at home on 4 April 2020. She had undergone a colonoscopy in December 2019 (with excision of two benign polyps and discovery of mild internal haemorrhoids), and an operation for a femoral hernia repair which had led to a bowel obstruction in January 2020. Ms Weekes frequently attended on Dr Yeo between January-March 2020, and he considered that her bowel function was ‘slowly improving’.
On 3 April 2020, Ms Weekes arranged a telehealth consultation (TC) with Dr Yeo. She reported that she had been vomiting and had abdominal pain for two days. She reported no diarrhoea, slight constipation, and feeling sweaty. She believed she was suffering from gastroenteritis.
Dr Yeo guided her through a self-examination of her abdomen and (based on her reported symptoms and findings of no abdominal mass) he concluded that Ms Weekes was suffering from gastroenteritis and completed a prescription for Maxolon with general advice on managing gastroenteritis including staying hydrated. He advised her to seek further treatment if her condition did not improve.
On 4 April 2020, Ms Weekes condition deteriorated. She attempted to book a locum doctor at 6:45pm but was unsuccessful. She called for an ambulance at 6:51pm but assistance did not arrive until 8:06pm (72 minutes after her call) and she was found dead on arrival. Her cause of death was acute aspiration complicating bowel obstruction.
An inquest was conducted into the death of Ms Weekes to examine (1) the nature of telehealth consultations and the clinical dangers associated with them and (2) the South Australian Ambulance Service’s procedure for responding to emergency calls.
The Outcome
The Deputy State Coroner (Coroner) found that, at the time of her consultation with Dr Yeo, Ms Weekes’ death was preventable. Whilst acknowledging that Dr Yeo was a ‘highly competent and caring GP’, the Coroner found that Dr Yeo placed too much reliance on Ms Weekes’ self-assessment, the TC should have been an in-person consultation because of the need for a physical examination given her history, and had she been seen in person she would have been treated differently (and most likely been referred to a hospital where her condition would have been diagnosed).
The Coroner’s findings were informed by the independent GP opinion that:
- the diagnosis of gastroenteritis was erroneously made based on a history of vomiting, but not diarrhoea;
- abdominal pain was not usually a feature of gastroenteritis unless coupled with diarrhoea bowel actions;
- the history of recent abdominal surgery should have alerted Dr Yeo to the risk of bowel obstruction;
- the history of vomiting, recent history of bowel obstruction, and co-morbidities ‘mandated’ a direct medical physical examination.
Dr Yeo conceded that bowel obstruction should have been at the forefront of his mind based on Ms Weekes’ history of abdominal surgery and symptoms as described via TC.
Implications
The Coroner recommended that ‘All South Australian [GPs] are provided with and reminded of the importance of The Guide in providing telephone and video consultations in general practice’.
The Guide provides useful guidance on when, and importantly when not, to use a TC. The Guide stipulates that TC are generally not to be used for assessing patients with potentially serious, high-risk conditions requiring a physical examination.
Practitioners should familiarise themselves with The Guide and ensure that they are encouraging patients to attend for in-person consultations in appropriate circumstances including where a physical examination is required and/or where a patient’s ability to community by TC is compromised.
To read the Findings of Inquest, click here.
