Barbara Kelly died from an anaesthesia overdose during a routine operation at Mackay Base Hospital
A Glenella grandmother died following an anaesthesia overdose during a routine operation at Mackay Base Hospital. Her family have now filed a $900k lawsuit.
Mackay
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A coroner has found inadvertent "human error" from a Mackay Base Hospital health care professional is likely behind the tragic death of a Glenella grandmother during a routine operation.
Barbara Kelly, 66, had been scheduled for shoulder surgery on September 6, 2019 when she was administered between eight and 16 times the recommended dose of metaraminol while undergoing anaesthesia.
As a result her blood pressure spiked, causing a previously undiagnosed aneurysm to rupture resulting in a "grade 4 sub-arachnoid haemorrhage".
Hospital staff took steps to reverse the effects of the already administered anaesthesia, but sadly she died two days later.
Details of her tragic death have been revealed in a $900,000 damages claim from Mrs Kelly's husband Neil Kelly and her three grandchildren, Brylee and Eloise Jorgensen and Isaiah Kelly, against Mackay Hospital and Health Service.
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Coronial findings included in the case, filed in the Supreme Court of Queensland and viewed by the Daily Mercury, state a syringe driver - which is a machine that can be programmed to deliver precise amounts of medication - was used to administer the sedation drugs.
"It was noted by the (anaesthetist) team that the amount of metaraminol Mrs Kelly was proposed to be administered was in the range of 5-10 millilitres/hour and the syringe driver was noted to display that she was receiving 80mL/hour at the time her blood pressure spiked," Coroner David O'Connell said in his findings.
Under a coronial direction, the machine in question was tested for any malfunctions.
"It is significant that the testing of the syringe driver found no fault with the machine," Mr O'Connell said.
"What is clear from the interrogation of the machine is that there were a number of changes of dosage of metaraminol programmed into the syringe driver in the short period before Mrs Kelly suffers the catastrophic event."
Machine data revealed there had been seven dosage changes between 8.36.42am and 9.40.29am, when the fatal dose was programmed.
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These dosages included 0.1, 10.1, 8.1, 2, 5, 10 and then 80mL/h.
"No individual in the anaesthetic team could be specifically identified as the one adjusting the infusion rate on the syringe driver at 9.40.29am and no person volunteered this information in a statement," Mr O'Connell said.
The findings stated that once a doctor noticed the blood pressure spike, "her alleged first comment was to ask if anyone had touched the pump or changed the rate, which was denied by others".
"On the information available I cannot precisely conclude who set the 9.40.29am rate, but logically it would have been one of the anaesthetic team," Mr O'Connell said.
"This case does not appear to me to be anything other than inadvertent, and very unfortunate, human error.
"It appears very likely to me that one of the clinicians in the anaesthetic team sought to enter the key strokes for an 8ml/hour infusion rate but inadvertently entered an 80ml/hour infusion rate.
"It may simply be that they did not see that there was no decimal point entered between the numerals 8 and 0."
Mr O'Connell added, this may not be precisely what occurred "but it is certainly one very plausible explanation". He dismissed any notion of it being a deliberate act.
"This appears to be a case of very unfortunate human error, with a tragic outcome," Mr O'Connell said.
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Mrs Kelly's family in late March filed a negligence lawsuit totalling $908,125.80 in the supreme court alleging the hospital breached its duty of care in relation to the death.
Documents state the hospital has denied liability over the death.
Mr Kelly, 68, and his grandchildren have sought damages for loss of dependency as a result of alleged negligence by the hospital.
A medical report from Dr John Moloney, included in the court case file, stated the metaraminol infusion "at approximately 10 times the planned dose did not meet an appropriate standard of care".
Lawyers for the hospital, in a document dated January 22, 2021, stated the hospital denied liability for the dependency claims "on the basis that the (hospital) has not yet completed its investigations into liability, and these remain ongoing".
Paperwork filed by Gene Paterson, solicitor for the family, also revealed in early February 2021, lawyers for the hospital requested another three months to be able to provide a "meaningful" response under the act.
During a compulsory conference held on March 4, 2021 "no explanation has been given for the (hospital) requiring an extra three months to carry out investigations to finalise the (hospital's) views regarding liability", Mr Paterson said in an affidavit filed with the case.
The Daily Mercury contacted Mackay Hospital and Health Service for comment.
"It is inappropriate to provide any comment on this matter as it is subject to legal proceedings," a MHHS spokeswoman said.
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Originally published as Barbara Kelly died from an anaesthesia overdose during a routine operation at Mackay Base Hospital
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