An elderly man has died from complications relating to the ingestion of bowel preparation, after several junior doctors at a tertiary hospital failed to alert senior doctors to his deterioration.
‘RR’, an 86-year-old man, who had undergone a subtotal colectomy for bowel cancer a year earlier and had untreated paroxysmal atrial fibrillation, was scheduled to undergo colonoscopy to investigate recurring abdominal pain at the unnamed tertiary hospital in Queensland.
At the time he was admitted, the gastroenterology intern noted his blood pressure was 94/55, heart rate was 100 BPM and he was nauseous – observations which the hospital’s director of gastroenterology would later say should have sounded alarm bells.
Due to a bed shortage, RR was taken to an outlying ward where he was treated by staff who were not familiar with administering bowel preparation.
The preparation commenced at 5.30pm and soon afterwards RR began to vomit.
Over the course of the night the vomiting continued.
A total of four resident doctors were contacted five times throughout the night by nursing staff; at various times, the renal and surgical ward doctors each prescribed different antiemetics.
By 2.30 am RR had finished the first jug of bowel preparation – a total of 3L – and had vomited several times, but at no point was his deteriorating condition escalated to a senior doctor.
By the next morning, he developed aspiration pneumonia and went into rapid atrial fibrillation.
He refused intensive care and died the next day.
When the case was reviewed, the gastroenterologist who admitted RR to hospital was highly critical of his management by the ward call doctors.
“She identified a range of issues she considered could have possibly prevented the aspiration and death including lack of appropriate and timely medical review, failure to recognise a deteriorating patient or possible signs of gut obstruction, failure to refer to a senior person such as a medical registrar or gastroenterologist on-call and “over the phone” prescribing large amounts of anti-emetic without examining the patient.
Meanwhile, the hospital’s director of gastroenterology acknowledged that on admission RR’s heart rate was increased and his blood pressure was low and “considered in retrospect, it would have been more appropriate to investigate this further and potentially abandon the colonoscopy”.
In her finding Coronial registrar Ainslie Kirkgaard said the complications RR experienced “arose because of a failure to recognise he was not tolerating the bowel preparation and was at risk of aspiration”, noting that multiple ward call doctors failed to escalate the case for senior medical officer review and allowed the administration to continue.
Ms Kirkegaard said she was satisfied the review of the case had led to appropriate changes at the hospital.