Doctor under investigation after patient dies

A NSW doctor has been referred to the medical board for “investigation of his clinical conduct” after the coroner found he withheld antibiotics from a patient who subsequently died.

Grandmother Maureen Anne Smith, 75, died in Armidale Rural Referral Hospital on April 1, 2018, following “systematic errors” that resulted in a delay of her transfer between hospitals, and a delay in the commencement of antibiotics.

Dr Robert Jauncy Hakwa Natukokona has been referred to the Medical Council of NSW by the Coroner for “investigation of his clinical conduct”.

That meant, Deputy State Coroner Harriet Grahame wrote, that “her prospects of survival were diminished by the fact that she ultimately did not receive appropriate care”.

Smith was initially admitted to Glen Innes District Hospital “suffering uncontrolled pain”, and following a conversation between the locum medical officer at Glen Innes and the accepting orthopaedic registrar at Armidale, a decision was made to transfer Smith for a knee aspiration.

However, the mother of two sons – who the coroner described as “strong and independent” and had been active in the care of her grandchildren when she lived close to them – was not transferred until the following day, which had a “cascading effect” on the provision of antibiotics, and she subsequently died.

Dr Robert Jauncy Hakwa Natukokona, who had been practising as an orthopaedic registrar in Australia for 15 years when Smith died, was the on-call orthopaedic specialist at Armidale Rural Referral Hospital. He directed the doctor at Glen Innes to withhold administering antibiotics, and instead told the doctor to give Smith paracetamol if a fever developed overnight.

The coroner found that this decision, when it was clear there would be a delay in her transfer, impacted her chances of survival.

“[There were] shortcomings in the standard of care provided to Maureen, including failures to identify cognitive deterioration and other ‘soft’ signs of septicaemia; the inappropriateness of a decision to withhold antibiotics in respect of suspected sepsis, when it was clear that Maureen would not be transferred on 31 March 2018; the lack of appropriate and timely observations; and failures to escalate transportation issues,” the coroner wrote.

Natukonkona, in his evidence during the inquest, told the court he saw no swelling, and no obvious drainable joint effusion when he examined Smith’s knee. However, the coroner said photographs of the grandmother’s knee showed clear swelling, even to a layperson.

But the coroner found that his evidence “should be treated with caution” and did not accept that language difficulties, as his lawyer had submitted, explained discrepancies in the accounts he gave the court.

“I remain concerned about the doctor’s honesty and capacity to engage with this inquiry with openness and insight … a number of his explanations were inherently implausible,” she wrote.

“He was unwilling to make concessions on untenable positions or to concede the possibility that his recollection had been impacted by the passage of time.”

As a result, the Coroner referred Natukonona to the Medical Council of NSW.

The Herald spoke to Natukokona’s lawyer, Andrew Deards from Makinson d’Apice, but despite multiple requests for comment, did not receive a response. Natukokona was also contacted via social media, but a response was not forthcoming.

Natukokona is still registered to practice medicine in NSW, according to the Australian Health Practitioner Regulation Agency. His registration is listed as East Albury and expires next year.

The coroner also criticised both hospitals and recommended an audit of nursing records at GIDH and better communications between NSW Ambulance and other patient transport agencies, and asked that the parties involve the treating doctor in transport decisions.

She asked for the implementation of a medically agreed-upon timeframe for patient transport, and recommended that NSW Ambulance also audit its overflow transfer requests.

Hunter New England Local Health District executive director of rural and regional health, Susan Heyman, apologised to Smith’s family, conceding “we did not provide her with the standard of care she deserved”.

She said HNELHD had provided GIDH staff comprehensive training on the identification and management of sepsis and delirium since Smith’s death, and had developed new guidelines for the management of a septic joint, where patients are now administered antibiotics before they are transferred to another health facility, if they are not transferred within 12 hours.

After-hours specimen processing protocols have also been updated, and sepsis blood cultures are now deemed an emergency, she said.

A spokesperson for NSW Ambulance told the Herald the organisation would consider the coroner’s recommendations.

The Morning Edition newsletter is our guide to the day’s most important and interesting stories, analysis and insights. Sign up here.