Inquest: Doctors failed to detect ‘substantial injuries’ days before Tasmanian woman’s death

Shirley Button complained of headaches and nausea and her heart stopped for six seconds just the day before she died. But doctors failed to record these major medical events.

Launceston General Hospital.

DOCTORS failed to detect “substantial injuries” to an elderly woman’s brain and spine that led to a her death two days after a fall, a coroner has found.

Coroner Simon Cooper said the care 69-year-old Shirley Gwendoline Button received “must be recognised as being of concern” and had the potential to have endangered her life.

Mrs Button, who lived in a retirement village in Prospect, was walking with friends when she tripped, hit her head on a brick wall and fell to the ground.

She was unconscious about a minute before she regained consciousness, told her friends she had a headache and was having trouble seeing and vomited.

She was taken to Launceston General Hospital by ambulance.

Mr Cooper said Ambulance Tasmania notes clearly indicated she had significant head and neck trauma.

Doctors detected Mrs Button’s heart rate was rapid and found a laceration and abrasion on the back of her head.

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Launceston General Hospital. Picture: PATRICK GEE

She was sent for CT, which revealed she had fractured vertebrae and enlarged lymph nodes in several regions.

“However, it was interpreted by the treating emergency physician as ‘negative for any major

injury’,” Mr Cooper said.

A haematoma on Mrs Button’s brain was also missed by the emergency physician and, “more significantly”, by the radiologist concerned with interpreting the results.

The next day, Mrs Button complained of headaches and nausea and her cardiac monitor alarmed and showed her heart stopped for six seconds about midday.

“It was suggested that there was no need for cardiological review of Mrs Button but that she should continue to be monitored.”

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Mrs Button’s condition deteriorated and “she was sent for CT scans of her brain and spine which demonstrated a large subdural haematoma on the right with midline shift and herniation.”

A plan was made to send Mrs Button to Hobart for neurosurgical management, but she deteriorated rapidly.

After consultation with family, she was transferred to a single room in the ED and provided with end of life care.

Mrs Button died just before midnight on November 19.

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An autopsy uncovered “substantial injury” including the haematoma and spinal fracture.

The then State Forensic Pathologist Dr Christopher Hamilton Lawrence said Mrs Button died as a result of the haematoma and Mr Cooper accepted his opinion.

The emergency physician acknowledged on review that he did not see the C3 fracture and the radiologist offered his apologies for “failing to detect what he described as a very small and subtle right tentorial haematoma’”.

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A review of medical reports and the treatment received by Mrs Button was undertaken by medical adviser to the Coronial Division, Dr AJ Bell.

He agreed that initial CT scan showed a subtle subdural haematoma and that although the existence of the haematoma was missed by the reporting radiologist, the diagnosis was a difficult one.

“I am satisfied that there is no basis to criticise the radiologist in the circumstances,” Mr Cooper said.

“Similarly, it is not reasonable to have expected the consultant emergency physician to have detected the presence of the subdural haematoma, given the fact the radiologist did not.”

Mr Cooper said the spinal fracture was a “different issue”.

“The fact that the fracture was ‘missed’ is difficult to understand in light of the fact that it is expressly mentioned in the radiological report that accompanied the CT scan results.”

Mr Cooper made no findings or recommendations.