A man who died days after a Burnie road crash received below standard care from the North West Regional Hospital, a coroner said.
“Specifically, there was a failure on the part of medical staff to diagnose fractured ribs and a failure to recognise significant bleeding causing respiratory impairment which, in turn, led to acute kidney failure,” coroner Simon Cooper said in his record of investigation of the death of Grant Godfrey Maynard.
Mr Cooper found Mr Maynard, 60, died at the hospital, on September 17, 2019, as a result of injuries sustained in a motor vehicle accident.
The cause of death was found to be multi-organ failure due to co-morbidities brought on by the accident.
The crash was on Main Rd, Wivenhoe, on September 14, 2019.
Mr Maynard, an Aboriginal education officer, was driving his own vehicle and it crashed into another vehicle at low speed, Mr Cooper said.
An ambulance took Mr Maynard to the hospital’s emergency department.
Mr Cooper said Tasmanian Health Service records indicated Mr Maynard’s vital signs were stable at the ED.
“He was reviewed by a medical registrar who discussed his case with the senior ED consultant,” Mr Cooper said.
“The medical officer recorded that it was considered that Mr Maynard had suffered a possible syncopal (fainting) episode.”
Mr Cooper said a chest x-ray showed a small pleural effusion (water on the lungs).
“There was no indication of rib fractures,” Mr Cooper said.
A CT scan was taken and Mr Maynard had to lie on his right side in the scanner because of left rib pain.
He was admitted to the hospital.
Mr Cooper said a consultant physician reviewed Mr Maynard the next morning.
The doctor noted Mr Maynard’s blood pressure was dropping as he moved from lying to standing, and his haemoglobin had fallen.
Further tests followed.
On the night of September 16, Mr Maynard was stabilised in the intensive care unit.
“The significant issues he faced were hypoxaemia and acute kidney injury,” Mr Cooper said.
“After discussion, Mr Maynard elected to receive pain relief and no increased medical care.”
Mr Maynard’s condition deteriorated
End of life palliative care started on September 17 and he died that day.
Comment was sought from Health Minister Sarah Courtney, including about whether the below standard care Mr Cooper said Mr Maynard received was part of a pattern or an isolated instance and, if a pattern, what would be done about it.
A government spokesperson said the government would consider Mr Cooper’s findings.
“Our thoughts are with Mr Maynard’s family,” they said.