Dying after performing an exercise stress test – an avoidable death in a Sydney hospital
Anna Walsh, Principal
A recent coronial inquest held in Sydney found that a lack of
education of junior doctors about hospital protocols, as well as
communication breakdowns between junior and senior hospital staff,
led to the death of 61-year-old former policeman Harry Coxell.
Treatment at hospital
Mr Coxell died after attending Blacktown Hospital with chest
pains in November 2006. He was taken by ambulance to the hospital
where he was treated in the emergency department by a doctor who
assessed him as being at an intermediate risk of suffering from
ischaemic heart disease. Mr Coxell was subjected to various
investigations and tests which were all reported as being normal.
Unfortunately, doctors looking after Mr Coxell did not consider
other cardiac conditions such as aortic dissection before deciding
that he could be transferred to the cardiac ward for ongoing
management.
On the ward, Mr Coxell was managed by a junior registrar who
failed to follow hospital protocols for the management of patients
with an acute coronary episode. This registrar also failed to
recognise that the ongoing chest pains Mr Coxell was experiencing
required a more senior doctor to review him. Mr Coxell was asked to
participate in an exercise stress test, an investigation that is
not advisable where there is a concern of an aortic dissection.
After running on the treadmill for more than seven minutes, the
test was terminated. Unfortunately, Mr Coxell then collapsed and
died.
Coronial
findings
The Coroner found that Mr Coxell died from cardiac tamponade
caused by an aortic dissection due to hypertension after
undertaking the exercise stress test. Importantly, the Coroner
found that Mr Coxell's death was avoidable. The Coroner criticised
the doctors for failing to apply clinical skills when considering
other cardiac conditions that Mr Coxell might have been suffering
from; placing too great a reliance on the general statistics of
patients presenting to hospital with chest pain; and not obtaining
advice from more senior doctors.
The Coroner made specific recommendations directed at improving
the quality of the management and care of cardiac patients within
the New South Wales Area Health Service. These recommendations
included:
- widening the existing guidelines to assist junior doctors with
diagnosing and managing conditions
- ensuring that senior doctors review patients when there has
been a change in a patient's condition
- developing an induction program to be presented by a senior
doctor to ensure that all junior and new medical staff are familiar
with the relevant protocols.
Importance of inquests
A coronial inquest into the circumstances surrounding the death
of patient in a hospital is a traumatic time for friends and family
of the deceased. However, it can help identify poor or risky
medical practice and has the added benefit of exploring ways in
which such outcomes can be prevented in the future. By
participating in a coronial inquest, the family of the deceased can
feel like the death of their loved one was not in vain and that
changes to medical practice or behaviour may be implemented so
tragedy can be avoided in the future.
Media statement