Hospital ‘lied’ to stop family probing Adam’s death, family alleges

The family of a man who died as a result of catastrophic errors at a Sydney hospital say they were lied to about crucial medical notes being destroyed as they probed the cause of his death after the files “embarrassingly” turned up during a coronial inquiry.

Adam Fitzpatrick died at St George Hospital after his breathing tube became dislodged following a car accident in the NSW Riverina. At the time of his death in 2020, Adam had stabilised, and his family had been told he was expected to be sitting up within days.

Philippa and Peter Fitzpatrick with their daughters Emma (on left) and Amanda (on second left) and Lucinda Eddy (on right), Adam’s girlfriend.Credit: Dominic Lorrimer

For two-and-a-half years, his family demanded his complete medical files and data, but was repeatedly told by the hospital the critical information had been deleted.

But as Adam’s case progressed to a 10-day hearing under Deputy State Coroner Derek Lee, this masthead can reveal the hospital’s own barrister, Anne Horvath SC, acting on behalf of South Eastern Sydney Local Health District, admitted the data that was crucial to determining how Adam died, had materialised.

“It’s a little embarrassing but not traumatic … we can actually get more data … which I know is what a lot of people, in particular the Fitzpatrick family, have wanted for a very long time, and that’s why it’s embarrassing that we haven’t been able to locate it earlier,” Horvath told the court.

“I appreciate that that is going to cause a number of people some confusion.”

Adam Fitzpatrick was ambitious and had planned to buy a block of land to settle down with his girlfriend.

St George Hospital director of medical services Heidi Boss also made admissions to the court. “We let the family down around that communication early on,” she said.

“We really failed you in that regard, and I am very sorry for that.”

Adam’s sister Amanda, a paramedic, and his mother Philippa, a veterinarian, “knew something wasn’t right when he died, we felt it with our medical backgrounds”, Philippa said. The family was initially told Adam’s death was unavoidable because the breathing tube had become blocked.

“(The hospital) just wanted us to go away, they drip fed us information, they thought they didn’t have to give us all the information, they just kept telling us it had been deleted, they lied to us to stop us probing,” Philippa claimed.

“It wasn’t until the inquest was under way that the data we had requested time and time again appeared.

“There needs to be more honesty, more transparency and people to take responsibility for what happened. How many families does this happen to? That walk out of that hospital without knowing? If we hadn’t fought for an inquest, none of this would have come out.”

On Tuesday, the coroner will hand down his findings, with counsel assisting recommending he find the inaction of staff at the hospital, when a number of doctors were equipped with the skills to save Adam’s life, resulted in his death.

While the ventilation and vital signs data was produced by the hospital at the inquest, the cardiac arrest code summary and scans taken at his bedside are yet to be found, Philippa said. The hospital has also failed to update Adam’s medical file to include a number of drugs that were administered on the day he died, despite giving the family repeated assurances the file would be reconciled.

The accident scene after Adam Fitzpatrick’s car crash.

Adam was starved of oxygen for 43 minutes after his breathing tube, inserted through a hole in the neck known as a tracheostomy, became dislodged. That put him into cardiac arrest and the lack of oxygen rendered him brain-dead.

A joint investigation by The Sydney Morning Herald and A Current Affair in 2021 found doctors failed to recognise the problem, were unable to fix it and decided against calling for the help of a specialist who could have replaced the tube in minutes and saved Adam’s life.

But evidence that came to light during the inquest was even more damning.

The court heard at least one of the 10 doctors who rushed to Adam’s room when alarms alerted them to a critical change in his condition, subsequently admitted to recognising that Adam’s breathing tube was displaced but did nothing to rectify the situation. Several others had the skills to identify that his tracheostomy was displaced, remove it and replace it, the court was told, but none did so.

The court heard the doctors felt obliged to follow a “Difficult Airways Poster”, despite it conflicting with their own views of its adequacy. There was evidence given non-technical skills, communication, leadership and teamwork skills were also lacking.

Independent experts called to provide evidence at the inquest were critical of Adam’s treatment, each recommending a review of tracheostomy management at state level to prevent further avoidable deaths, and asked the coroner to make a recommendation for standardised and mandated training.

One expert, Professor Carsten Palme, director of head and neck surgery at Chris O’Brien Lifehouse, described Adam’s case as “very sad and tragic” and told the inquest NSW’s public health system lacked “consistent education and training”.

“We can see by these emergency management plans, they’re complex, they’re inconsistent, they’re not correct, they vary from hospital to hospital,” Palme told the court.

Philippa told this masthead that days before Adam’s death, she had to reconnect the tube herself, because, despite her son being prescribed one-to-one care, he was often left unattended by nursing staff.

Philippa and Peter Fitzpatrick with their daughters Emma (on right) and Amanda (on left) and Lucinda Eddy, Adam’s girlfriend (on second right). Credit: Dominic Lorrimer

She questioned whether the coroner could carry out a comprehensive investigation, given Adam did not undergo an autopsy.

“After Adam died, we agreed to organ donation, but we asked if organ donation would prevent an autopsy from happening. They assured us it wouldn’t, and it would all be fine,” Philippa said.

“But in the end, no autopsy was even done and then there was only a vague cause of death given, ‘complication from blunt force trauma’ which isn’t even correct,” she said.

‘It seems that the HCCC is good at disciplining people who have sexually assaulted someone, but if someone kills a patient, there doesn’t seem to be any recourse.’

Philippa Fitzpatrick

The family also made several complaints to the Health Care Complaints Commission (HCCC) against the doctors involved in his care, a nurse and St George Hospital. Philippa said each of the complaints were dismissed.

“Of particular note, we made a complaint about Dr Paras Jain. Dr Jain was the most senior clinician that attended the incident and was the supervisor of training at the time. When we made our complaint to the HCCC, (it was) closed on the basis that specialist peer advice did not identify a departure in the clinical care provided to Adam,” Philippa said.

“Our complaint against St George Hospital was later closed as well, contradictorily, on the basis that the practitioner most responsible had been identified as Paras Jain, and there had been internal ramifications; a short period of suspension from St George and supervision, however during that time he was allowed to practise unsupervised at any other hospital. There has been no formal reprimand or consequences.”

Philippa said the family discussed an appeal of the commission’s decision but, by the time the complaint against the hospital was closed, the time permitted to lodge an appeal in relation to Dr Jain had expired. The family subsequently uncovered new information but the HCCC again declined to reinvestigate, Philippa said, as the matter was then under the carriage of the coroner.

She fears that because the commission had already reviewed the case, the coroner will not refer the hospital or anyone responsible for Adam’s care and subsequent death, for further investigation.

“Adam was a person, not just a patient, it just seems humanity is lost. We lost a son and a brother, but Adam lost everything. It’s lost that Adam had hopes and dreams, he was about to ask his beautiful girlfriend to marry him, they forget he was a person.”

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