A private hospital was not equipped to perform the high-risk and unnecessary bile duct surgery which led to the death of a Darwin grandmother, a coroner has found.
Both Darwin Private Hospital and a general surgeon have been criticised over the death of Irene Magriplis, 75, who died from sepsis three days after bile leaked into her abdomen from a 3mm hole in her duodenum following elective surgery to remove a non-malignant tumour.
In findings for a coronial inquest in March, Judge Greg Cavanagh said the 75-year old’s death was preventable and should not have occurred.
He found the Healthscope facility was not equipped to perform the high-risk procedure because it had neither an ICU, 24-hour access to gastroenterology and interventional radiology or the multidisciplinary team needed to make a proper diagnosis and treatment plan.
These risks were compounded by an inadequate escalation policy for deteriorating patients, and a high care unit where no on-duty nurses had post-registration intensive care qualifications, he said.
The coroner was also critical of Dr John Treacy who performed the procedure, finding he recommended resection for the “pre-malignant” tumour he now concedes was not necessary, and failed to inform his patient of the risks.
Mrs Magriplis first saw her GP for abdominal pain and nausea in February 2015.
After investigations revealed a tumour with no evidence of malignancy, the GP recommended further treatment be done interstate at a hepatobiliary unit due to the risk of complications.
But Dr Treacy told the woman he could perform the operation at Darwin Private.
“He did not tell her that the hospital was not properly resourced for such an operation,” Judge Cavanagh said.
“He did not tell her that he did not have access to a multi- disciplinary team. He did not tell her that she might die from the procedure.”
After the three-hour surgery on May 27, staff struggled to get Mrs Magriplis’s pain under control.
By the evening she was reporting extreme abdominal pain, and was taken to high dependency unit.
The next morning she went into septic shock, and in the afternoon was transferred to Royal Darwin Hospital ICU.
At 8 pm Dr Treacy reviewed his patient and concluded there was no need to re-operate.
However, about 1 am the next day he considered possible bile leak and re-operated, discovering a 3mm hole in her duodenum.
He repaired the hole and washed out her abdomen, but she suffered multiple organ failure and died the next day.
“There were many points at which the bile leak should have been addressed,” said Judge Cavanagh.
“She should not have died. In my view her death was preventable.”
Dr Treacy told the inquiry that he did not suspect Mrs Magriplis had a bile leak on the morning following the surgery because he never saw crucial information on her observation chart.
“It’s extremely worrying to me that I didn’t know there was 400mm [of bile] in the drain,” he told the inquest.
“I had never seen that until months after the event. I must not have looked at the chart or it was not written on the chart at the time.”
Judge Cavanagh remarked that in the wake of the tragedy, hospital operator Healthscope “seemed unwilling to recognise any lack of care or error”.
“To learn from such failures Darwin Private Hospital and Healthscope must be willing to identify and admit failures and follow their own policies to review them and improve.
“In this inquest they have not demonstrated an ability or willingness to do that.”
He recommended the Department of Health and the Top End Health Service consider the findings in relation to licensing Darwin Private Hospital, and referred the case to the Medical Board of Australia.