Misdiagnosis by Mersey Community Hospital staff led to Alexander Frank Patterson’s death, coroner’s report finds

A coroner found that the death of an East Devonport was ‘a certainty’ after misdiagnosis at a northern Tasmanian hospital. The full report:

The Mersey Community Hospital. Patients were transferred from the North West Regional Hospital in Burnie to the Mersey Community Hospital in Latrobe. Picture: PATRICK GEE

A coroner has concluded that had a 65-year-old East Devonport man been appropriately diagnosed when he presented to the Mersey Community Hospital (MCH), “he would have had a chance of survival.”

Alexander Frank Patterson died on May 22, 2023, after being transported to the MCH by ambulance earlier that morning.

In her report into Mr Patterson’s death, Coroner Olivia McTaggart said that he was diagnosed with “an infection with atypical pneumonia-causing confusion and hypoglycaemia.”

However, Ms McTaggart said the diagnosis was incorrect.

“Mr Patterson, in fact, was bleeding from a duodenal ulcer with a large artery in its base,” she said.

“About six hours after his presentation to hospital, Mr Patterson’s condition deteriorated quickly, and he became pale and unresponsive.

“Despite resuscitative measures, he passed away at 8.49pm that evening.”

Mr Patterson’s death was subject to a Tasmanian Health Service (THS) Root Cause Analysis (RCA) report and was analysed by coronial medical consultant Dr Anthony Bell.

Magistrate/Coroner Olivia McTaggart at the old railway roundabout in Hobart for a TasWeekend feature for International Women's Day. Picture: SAM ROSEWARNE.

Ms McTaggart said based on the opinion expressed in those reports, Mr Patterson’s gastrointestinal bleeding should have been diagnosed at his hospital presentation.

“If Mr Patterson had been diagnosed correctly with gastrointestinal bleeding, appropriate emergency treatment would have followed.

“This should have included urgent transfer for endoscopy or other surgical options to control the bleeding.

“Assuming a correct diagnosis and rapid escalation of care, Mr Patterson would have had a chance of survival.

“As the diagnosis was missed, his death was, unfortunately, a certainty.”

The RCA report noted that there had been a “premature diagnostic closure” and failure in communication of crucial information between clinicians, which led to the treating team making a diagnosis of pneumonia.

The report panel made four recommendations.

Two key recommendations from the report were that the Emergency Department at the MCH consider introducing a validated scoring scale and flowchart and pathway for the management of a suspected upper gastrointestinal haemorrhage and that the THS conduct audits of medical documentation to ensure it meets the requirements of the relevant National Safety and Quality Health Service Standards.

Commonwealth-funded Mersey Community Hospital at Latrobe

The Department of Health extended its condolences to Mr Patterson’s loved ones.

“We acknowledge the circumstances of this case and the comments of the coroner,” a department spokesperson said.

“As noted by the coroner, an independent RCA report was completed with four recommendations made.

“Two recommendations have been completed, including the implementation of a validated scoring scale, with a supporting pathway for the management of a suspected gastrointestinal haemorrhage under development.”

The department said the other two recommendations were “in progress” and set to be completed by the end of this year.

“All patients who present to our Emergency Departments are triaged using the Australasian Triage Scale system which helps to determine a patient’s complexity, clinical need and urgency.

“We are committed to continuously improving the health services provided in Tasmania, and we carefully review all coroner’s findings to learn from what has happened and to implement appropriate changes.”