Hospital system failures led to Christopher Essery’s sepsis death, Coroner finds

A Queensland coroner has condemned systemic failures at Brisbane’s Princess Alexandra Hospital that contributed to the death of a Far North Queensland man following his transfer from Cairns Hospital.

Hospital system failures led to Christopher Essery’s sepsis death, Coroner finds. NewsWire / Sarah Marshall

A Queensland coroner has delivered a scathing verdict on systemic failures at Brisbane’s Princess Alexandra Hospital that contributed to the death of a Far North Queensland man.

Christopher Glen Essery, 74, died in February 2019 after a lengthy battle with severe Crohn’s disease that saw him shuttled between Cairns Base Hospital and the Brisbane facility for complex treatment.

Mr Essery’s wife Susan had pushed for the coronial investigation, believing her husband’s death was due to failures in his medical care.

Deputy State Coroner Stephanie Gallagher found that while the care at Cairns Base Hospital was appropriate, critical systemic failures in Brisbane meant Mr Essery went more than two months without seeing a senior colorectal surgeon – despite being transferred specifically for specialist surgical input.

Deputy State Coroner Jane Bentley found that while the care at Cairns Base Hospital was appropriate. Picture: Brendan Radke

In contrast Deputy State Coroner Jane Bentley found critical systemic failures Princess Alexandria Hospital. NewsWire / Sarah Marshall

The damning findings reveal Mr Essery was transferred from Cairns in August 2018 after three months of failed medical optimisation, with expectations he would receive urgent specialist care at Queensland’s premier hospital.

Instead, he was subjected to the same failed treatment protocols that hadn’t worked in Cairns, while the specialist colorectal surgeon responsible for his care, Dr Peter Gourlas, went on extended leave without ensuring proper handover arrangements.

“No single Colorectal Surgical Consultant took up the responsibility for, or ‘ownership’ of Mr Essery’s care during the period of Dr Gourlas’ extended leave,” Coroner Bentley found.

When Mr Essery finally saw a consultant surgeon in November 2018, he was deemed too unwell for surgery. By the time Dr Gourlas returned from leave, Mr Essery’s condition had deteriorated to the point where surgery became extremely high-risk.

The coroner was particularly scathing about PAH’s failure to review what had already been tried at Cairns Hospital, describing herself as “absolutely frustrated” that staff didn’t examine three months of previous treatment records.

The case highlighted critical gaps in Queensland’s hospital system, where complex patients can fall between the cracks during staff leave periods, the coroner found. Picture:iStock.

Mr Essery underwent complex surgery in January 2019, revealing multiple complications including five bowel fistulas. Despite additional procedures, his condition continued to deteriorate and he died on 20 February 2019 from sepsis.

The case highlighted critical gaps in Queensland’s hospital system, where complex patients can fall between the cracks during staff leave periods, the coroner found.

But the report said earlier surgery may not have changed the outcome because he was already in such poor condition and the same complications would have likely occurred.

The coroner emphasised that such system failures “could result in significant adverse effect on other patients if it were to occur on other occasions”.

The Metro South Hospital and Health Service accepted the criticism, acknowledging the time frame for specialist review was “too long” and that better handover processes were needed.

Originally published as Hospital system failures led to Christopher Essery’s sepsis death, Coroner finds