Hospitals to blame for patient's death

[okarol]

Hospitals to blame for patient's death

Natasha Wallace Health Reporter
December 6, 2007

WAYNE BROWN was in the wrong place at the wrong time - Blacktown Hospital - which did not have the equipment to treat his fatal kidney disease. The closest hospital that did, at Concord, had no available beds.

Mr Brown, 40, of St Marys, died on December 14, 2003, of heart failure as a result of end-stage renal disease, Bankstown local court heard yesterday.

Handing down the findings into his death, the senior deputy state coroner, Jacqueline Milledge, criticised all three hospitals involved in Mr Brown's care - Nepean, Blacktown and Concord - for a combination of poor case management, ineffective treatment and ultimately failure to diagnose the heart condition that killed him.

Ms Milledge told the court that allowing Mr Brown to leave Concord Hospital on December 12 and travel home by public transport had disastrous consequences.

The case highlights a system in crisis with a lack of lifesaving equipment and beds, and emergency doctors run off their feet.

The findings come amid three months of continued pressure on the State Government over a bed shortage and the need for more senior medical staff in Sydney's chronically overloaded public hospitals, particularly emergency departments.

Mr Brown was diagnosed and treated for acute kidney failure at Nepean Hospital in August 2003, but his condition was not followed up. He collapsed at home on December 4 and was rushed to Nepean Hospital. The next day he was transferred to Concord for urgent dialysis.

He was discharged from Concord on December 12 and told to come back in the morning for more dialysis. Despite being so ill, he was allowed to travel by public transport.

He failed to make the 1pm appointment at Concord and was instead rushed again by ambulance to Blacktown Hospital.

However there were no dialysis machines and he waited in emergency, for more than six hours, because Concord Hospital did not have an available bed.

"Mr Brown was in urgent need of dialysis and needed to be transferred as quickly as possible. He was on fluid overload and six hours was a deadly waste of time in a critically ill patient," said Ms Milledge.

She said none of the doctors at Blacktown diagnosed him with cardiac tamponade, which would have increased the urgency for a bed. "Sadly much of the treatment was untimely and inappropriate," she said.

She said the doctors in Blacktown emergency were overloaded and this compromised the handover to ambulance for Mr Brown's transfer on the morning of December 14.

"Mr Brown could be said to have been in the wrong place at the wrong time," Ms Milledge said.

Mr Brown's sister Kim McCall said she was disappointed by the findings because she wanted the doctors responsible for his care to be held more accountable.

"The system let him down and he's dead and I really wanted accountability," she said.

Earlier she told the court: "I am very sorry but I have no room in my heart for forgiveness as part of my heart went with Wayne."

http://www.smh.com.au/news/national/hospitals-to-blame-for-patients-death/2007/12/05/1196812824896.html

[Black]

This an awful situation but this happens in every county and every community sooner or later.

Last winter during peak flu season we had a woman at a local large hospital lying on the ER waiting room floor, next to where her husband was sitting.  She was lying in vomit and fecal material.  Her eyes were closed and she frequently groaned, occasionally interrupted by retching sounds.  My friend watched a nurse come out of the back carrying a bucket and a roll of paper towels.  She handed them to the husband and told him to clean up the mess, and then take her into the bathroom and clean her up.  The husband cleaned up as well as he could with dry paper towels, took the bucket outside and dumped it into an outside waste barrel.     

When my friend left with her daughter the woman was still lying on the floor, drooling and moaning, with vomit and fecal material on her clothes.  And the outside barrel was still sitting there breeding God knows what.

Everyone needs to know that ER triage is sometime poorly and inefficiently organized.  If they suspect their situation is critical they need to be insistant and aggressive in getting immediate treatment.  If ignored long enough I would have no problem faking a heart attack to get attention.

I hope Mr Bown's family is able to force the hospitals to make changes.

[Sluff]

Totally uncalled for.

[goofynina]

There is no such thing as being at the wrong place at the wrong time, he met his destiny.  This is truly a sad story but i believe it was just his time,  God Bless his soul.