Four Sydney doctors referred to medical board over hospital death

Four Sydney doctors have been referred to the medical board for investigation after a state coroner found their actions led to the death of a 20-year-old man at St George Hospital.

Deputy State Coroner Derek Lee told the court on Tuesday that there was enough evidence presented during the inquest into the death of Adam Fitzpatrick for the clinicians – Dr Paras Jain, Dr Ajey Dixit, Dr Hemang Doshi and Dr Ashima Sharma – to be referred to the Medical Council of NSW as he believed they had engaged in “unsatisfactory professional conduct” and “demonstrated a lack of medical competence”.

Adam, with his sister Amanda (left), mother Philippa, father Peter and sister Emma (right)

Fitzpatrick died in 2020 following a series of catastrophic errors by staff at St George Hospital after a car crash in the NSW Riverina.

The injuries he suffered in the crash were survivable, Lee ruled, but it was the actions, or inaction, of doctors when his breathing tube, known as a tracheostomy, became dislodged that caused his brain to be starved of oxygen, and Fitzpatrick went into sustained cardiac arrest.

“Adam died in circumstances where dislodgement of the tracheostomy was recognised or suspected by clinicians involved in his care. However, timely and definitive management of the clinical situation was not instituted to remove and replace his tracheostomy tube,” Lee told the court.

“This had the consequent effect of delaying effective management of Adam’s airway and resuscitation efforts.”

One of the clinicians, Doshi, admitted during the inquest that he had recognised that the tube was displaced but did not raise his concerns to the other doctors, as they outranked him at the hospital.

Fitzpatrick died five days before his 21st birthday. The youngest of three siblings, he had almost completed a degree in agriculture production and management, and was formulating a plan to propose to his girlfriend.

The family was initially told by the hospital that his breathing tube had become blocked, and his death was unavoidable. But the nous of his mother Philippa, a veterinarian, and his sister Amanda, a paramedic, meant the family engaged in a two-and-half year plight to find the truth.

“We knew what happened at the hospital that day wasn’t right,” Philippa said outside court on Tuesday.

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

The findings follow revelations by this masthead that the hospital withheld crucial information from the family in the wake of Fitzpatrick’s death, as they probed why he had died so suddenly. The family claimed this was an attempt to cover up the errors that led to Adam dying, as the hospital’s own barrister admitted the files “embarrassingly” appeared as the inquest hearing got underway.

Lee found that the manner in which St George Hospital communicated with the Fitzpatrick family was “not entirely adequate”, and they were not “immediately provided with a clear understanding” of what happened to their son and brother and that “further, legitimate queries” held by the family “were not addressed in a clear and forthright manner.”

He added that while stress and emotion involved in the high-pressure situation “may explain the miscommunication, it does not excuse it.”

Dr Paras Jain

Fitzpatrick’s medical notes will also be amended following the inquest, “to accurately reflect what occurred” on the day he died, something his family had campaigned for. Prior to the inquest the records were incomplete, with events and actions of the doctors, as well as medication that was administered on the day he died, missing from his files.

Fitzpatrick’s family had hoped, as had several of the independent experts called to give evidence during the inquest, that the coroner would make a recommendation for a statewide review of the systems and procedures around tracheostomy management, but the coroner declined.

There were no recommendations made against the hospital, either, as the coroner said the administration had already taken steps to implement training around tracheostomy management and staff communication, to ensure that in crisis situations, avoidable deaths, such as Fitzpatrick’s would not occur again.

Dr Hemang Doshi

“It’s heartbreaking to sit and hear all over again how little the doctors did and, this morning I wondered if we had fought for this for nothing, but some of the doctors have been referred (for review) and I just hope that this makes other families aware that this can happen, and that they ask questions, if they have any doubts that they speak up,” Philippa said.

“I hope, too, it makes the doctors think a little bit, that maybe they are accountable that they can’t just walk away, they are responsible for people’s lives.

“It’s too late for Adam, but hopefully, we can help some other family save their child. And that can be Adam’s legacy.”

Adam’s father, Peter, said the findings felt like vindication for the family, and that their fight for the truth had not been for nothing.

“When we first heard he was being flown to St George we thought ‘good’, because we thought it would be a top hospital, you know, he’s in the clear, the care would be exceptional. We were wrong,” he said.

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