NT Coroner releases findings over Judy Smart’s death following ‘inadequate’ care in Royal Darwin Hospital
The heartbroken family of a Territory grandmother have described her shocking condition following 10 days of ‘inadequate’ treatment in Royal Darwin Hospital following a routine knee surgery.
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A Northern Territory grandmother who went into Royal Darwin Hospital for a routine surgery was exposed to “inadequate” post-operative care before her death, the coroner has determined.
On Wednesday, Elisabeth Armitage released her findings into the death of 66-year-old Judy Smart in the Royal Darwin Hospital on June 20, 2021 — just 10 days after checking in for a knee surgery.
Ms Armitage found that within hours of her “straightforward and uneventful” surgery, Ms Smart was found unresponsive in her hospital bed after suffering a cardiac arrest.
No medical staff were alerted to her heart attack, or that oxygen was cut off from her brain for at least 15 minutes before the ‘high risk patient’ was discovered.
Ms Armitage heard Ms Smart started to suffer knee issues seven years before her death, and spent 20 months on the surgical waitlist for the “revisionary resurfacing” of her right kneecap before her surgery on June 10.
She was flagged as being at higher risk for anaesthesia complications, due to her comorbidities including needing a Continuous Positive Airway Pressure (CPAP) machine for sleep apnea.
After her surgery Ms Smart was taken to the Post Anaesthetic Care Unit, showing signs of pain but was conscious, chatting to a nurse about her husband and asking about her belongings.
At no point was her CPAP machine brought to her bedside, and Ms Armitage said there was confusion among nurses over who had responsibility for collecting her personal items and medical device.
Around 90 minutes after arriving in PACU, nurses flagged Ms Smart’s oxygen levels would drop whenever she fell asleep and she needed to be “frequently roused”.
However amid the “considerable pressure” of the busy hospital, floor anaesthetist Andrew Magness modified her discharge criteria without a full clinical review.
Ms Smart was moved from the intensive one-to-one observation ward to a general surgical ward, where each nurse has to care for six patients.
Around 7.30pm the general ward nurse found Judy unresponsive with no pulse — her oxygen levels had dropped to 77 per cent.
“Apparently, the alarm had not gone off or had not been heard,” Ms Armitage said.
It is estimated Ms Smart lost oxygen to her brain for at least 15 minutes, and after eight days in the intensive care unit her family made the heartbreaking decision to transition her to hospice care.
But despite her family’s wishes, Ms Smart was shuffled to a general ward but the Palliative Care Team was not told of her transfer.
When her husband, children and grandchildren went to say their goodbyes, they found her “agitated, hot, clammy”, struggling to breathe and with a full catheter bag.
They waited up to 50 minutes trying to get assistance from a doctor, before they had to leave the overwhelming and distressing scene.
Palliative Care Registrar Dr Abbey Le Blanc told the coroner Ms Smart’s death with “uncontrolled symptoms was the antithesis of appropriate palliative care”.
Ms Armitage said NT Health had accepted failings in Ms Smart’s treatment, flagging changes in PACU staffing and discharge process, the management of patient belongings, monitoring of patients and end-of-life care protocols when hospice is not an option.
“NT Health accepts there is a gap in its service provision for high-risk patients who require closer observation than is available on general wards,” she said.
Ms Armitage said given these changes within the health system as a result of Ms Smart’s death, she had no further recommendations.
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Originally published as NT Coroner releases findings over Judy Smart’s death following ‘inadequate’ care in Royal Darwin Hospital
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