Diagnosis and treatment delays at Calvary Hospital meant man ‘lost significant chance of survival’

A Tasmanian coroner’s findings point to an 18-hour delay in diagnosis and treatment as the biggest factor in the death of a retired Oatlands farmer. The full report:

Hobart Hospitals private and public are pictured as the coronavirus / COVID-19 pandemic worsens. Calvary Lenah Valley Hospital, Augusta Road, Lenah Valley / New Town. Picture: MATT THOMPSON

A Tasmanian coroner has found that a retired farmer “lost a significant chance of survival” in 2021 after an 18-hour delay in diagnosis in the emergency department of a Hobart hospital.

James Fredrick Hill, 74, passed away from loss of blood flow to his bowels at the Royal Hobart Hospital in December 2021 after a delay in diagnosis and treatment at the Calvary Lenah Valley Hospital.

Coroner Olivia McTaggart handed down her investigative findings into the Oatlands man’s death on Thursday of “numerous deficits in Mr Hill’s treatment that contributed to a delayed diagnosis and treatment” at Calvary.

Mr Hill was transported to Calvary by ambulance on December 14, 2021, after a fall onto his hip left him with abdominal pain.

After he was admitted, Mr Hill had X-rays of his hip and was transferred to the orthopaedics ward, despite no fractures being found in his hip.

Doctors and nurses pulling hospital trolley,

Mr Hill’s blood was not tested for four hours, but his blood pressure indicated a systolic reading higher than 90.

At 2.30am on December 15, around 12 hours later, Mr Hill’s observations showed a “very low blood pressure, drop in oxygen saturations, increase in resting heart rate and increase in temperature” which met the criteria for a Medical Emergency Team.

However, this did not occur.

Instead, Coroner McTaggart said hospital staff continued to monitor Mr Hill and his decline in health, including vomiting, abdominal pain and urine and blood samples “consistent with multiple organ dysfunction”.

At 12.30am on December 16, 2021 a CT scan revealed a long segment of dead small intestine, which prompted Calvary staff to transfer Mr Hill to the Royal Hobart Hospital (RHH) as he required urgent surgery.

Hobart Hospitals private and public are pictured as the coronavirus / COVID-19 pandemic worsens. Calvary Lenah Valley Hospital, Augusta Road, Lenah Valley / New Town. Picture: MATT THOMPSON

Surgery soon revealed that Mr Hill’s entire small intestine was dead and he could not survive, with RHH staff placing him in palliative care until his death at 5.43am.

Coroner McTaggart noted Calvary’s own Serious Clinical Incident Investigation into Mr Hill’s death which said a Medical Emergency Team “should have been called to Mr Hill as early as 2.30am on 15 December 2021”.

Calvary’s investigation also found that earlier intervention may not have “resulted in a different and better outcome for him”.

Coroner McTaggart concluded that Mr Hill’s chances of survival were impacted by a “delay of almost 18 hours in diagnosing this condition and initiating urgent treatment”.

“The Calvary investigating team made comprehensive recommendations for improved processes, education and training,” she said.

“I am satisfied that the recommendations are responsive to the issues in this case and have been implemented by Calvary.”

Calvary Hospital was contacted for comment.

Originally published as Diagnosis and treatment delays at Calvary Hospital meant man ‘lost significant chance of survival’