‘Never afforded’ a chance of survival: Coroner slams hospital errors in wake of teen’s death

Launceston General Hospital has once again come under fire following a patient’s death, this time over a teenage boy who was “never afforded” a chance of survival.

Launceston boy Kane Leary as a child. Kane died at Launceston General Hospital in the wake of a motorcycle accident. Picture: Facebook

Launceston General Hospital has once again come under fire following a patient’s death, this time over a teenage boy who was “never afforded” a chance of survival.

In his newly-published findings, Coroner Robert Webster said Kane Leary, 17, died in May 2021 from a large stroke, caused by a tear in his left carotid artery, following a motorbike crash in Launceston.

However, the injury to his carotid artery was not detected on neck scans by after-hours, offsite radiologist, who reported “no abnormalities in the head and neck”.

“Whether this was due to inexperience, time pressures, oversight or some other reason is not known,” Mr Webster said.

“This gave a false sense of security to the treating clinicians.”

As a result, instead of Kane being sent to Hobart for time-critical brain surgery, Launceston staff focused on surgery on Kane’s right foot, which had been partially amputated in the accident.

Launceston General Hospital. Picture: Amber Wilson

By the time Launceston General Hospital (LGH) contacted the Royal Hobart Hospital neurological team, Kane had already suffered a major stroke – and it was too late to save him.

“The treatment, if performed, would have given Kane at least a chance of survival. Given what transpired, Kane was never afforded that chance,” Mr Webster said.

The coroner found that Kane hadn’t been wearing a helmet at the time of the crash, and that an unknown person had planted a helmet at the scene after the accident.

However, he said that even if Kane had worn a helmet, that would not have necessarily prevented the carotid artery injury.

“Ultimately it was the failure to identify and treat that injury that lead to Kane’s death,” he said.

Mr Webster made a number of recommendations, including that LGH update its trauma protocol and implement guidelines that provide direction on when its clinicians need to contact Hobart’s neurological team.

He said this should be done even when there was only a “minor suspicion” of head trauma.

Mr Webster also recommended the Tasmanian Health Service consider whether more radiologists should be employed in-house and after-hours.

A Department of Health spokesperson said it had implemented eight recommendations from an internal review after Kane’s death, including improvements in the management of trauma patients, “to ensure such events do not happen again”.

The spokesperson said in February 2023, a new statewide trauma bed-card and referral system was introduced to manage patients with complex trauma injuries, regardless of where they were in Tasmania, with 24/7 support from Hobart.

The LGH has come under repeated criticism in recent years over numerous patient deaths.

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