A man who died from a ruptured spleen following his discharge from a colonoscopy might have survived if he had received the correct medical advice from an on-call nurse service, a coroner has found.

The 70-year-old patient underwent the elective medical procedure at the Royal Melbourne Hospital in August 2018 after returning a faecal occult blood test as part of the national bowel cancer screening program.

He was discharged a few hours after the procedure, which lasted about 20 minutes and involved the removal of a small polyp.

The following evening, the patient experienced abdominal pain, dizziness and shortness of breath. At 10.44pm, his wife called the hospital and was transferred to the nurse-on-call service, provided by Medibank Health Solutions Telehealth.

Speaking with a triage nurse together with her husband, they detailed his symptoms, including feeling hot, giddy and short of breath. The patient was unable to continue the conversation and handed the phone back to his wife.

The nurse advised that the patient should maintain hydration, take Panadol for the abdominal pain and see a doctor within the next 12 hours, adding that the patient should call the service again or see a doctor sooner if symptoms persisted.

The patient took Panadol and went to bed at about 11pm. His wife found him unresponsive some hours later at about 3.15am, calling triple zero.

He was declared dead at the scene shortly after paramedics arrived, with an autopsy in the days after confirming the cause of death was a ruptured spleen.

Coroner Paul Lawrie found the nurse’s incorrect advice prevented the patient from getting to a hospital in time for emergency care, and given the patient’s complaint of breathlessness, the call should have been transferred to Ambulance Victoria.

“…the incorrect advice from the triage nurse resulted in a lost opportunity for emergency medical assessment and care which, subject to [the patient’s] clinical presentation at the time of the emergency treatment, may have prevented his death,” Mr Lawrie stated in his report, published earlier this month [link here].

It was agreed among all three expert witnesses – which included gastroenterologists – that the cause of the splenic injury was mechanical and attributable to the use of the colonoscope during the procedure, which was performed by a nurse colonoscopist who had received specific training.

She had performed 483 unsupervised colonoscopies following her training and 316 colonoscopies under supervision during her training, the coroner noted.

“The autopsy revealed adhesions between the mesentery and the spleen with splenic tissue identified firmly adherent to the mesentery. It was further observed that there was 1,000 mls of liquid blood surrounding the spleen and approximately 500 mls of clotted blood and the splenic capsule was deficient over an area of 5 cm x 3 cm. The deficiency was the result of either a small tear leading to bleeding or a sub-capsular haematoma which has ruptured,” the coroner wrote.

“In either event, the consequence was significant internal bleeding from the spleen leading to [the patient]’s death.”

The coroner said he was satisfied that splenic injury was rare and could occur regardless of the degree of expertise and care exercised by the colonoscopist. He said the procedure was routine and without the use of inappropriate force.

He recommended the Royal Melbourne Hospital review its written patient discharge information, which had “poorly presented” information on complications, to remove ambiguity and to include signs of significant internal haemorrhage.

It should also review its discharge procedures to ensure a record was kept of all the information provided to the patient, the coroner said.

The coroner was satisfied that Medibank had conducted an internal review and taken remedial steps in response to the triage nurse’s error, including amending its triage algorithms to include a question related to hospital discharge within the previous 48 hours and amending its induction and annual education program to place stronger emphasis on the importance of audible cues from callers.