A North-West man who waited two days for an MRI and subsequently died from complications from a stroke in 2012 may have survived if he had been transferred to the Royal Hobart Hospital immediately, a coroner has found.
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Coroner Rod Chandler led an investigation into the death of Darryl Charles Morris, 41, who died at the RHH six days after presenting to the North West Regional Hospital.
He released his findings on Thursday and made five recommendations to the Tasmanian Health Service.
“It is not possible for me to find that Mr Morris’ death would have been avoided if he had received optimal medical care.
“However, I am satisfied, and so find, that if Mr Morris had been promptly diagnosed and transferred that there was a real likelihood that he could have been successfully treated and made a functional recovery,” Mr Chandler said in his report.
Mr Morris presented to the NWRH in Burnie on September 6 after his wife found him lying on the ground outside their home. He died at the RHH on September 12 after a series of miscommunications.
He waited two days before being transferred to the Launceston General Hospital for an MRI and was immediately transported back to the NWRH before the results of the MRI were made available.
Records indicate the results of the MRI scan did not become available to the NWRH until September 11. Mr Morris died after being transferred to the RHH on September 12.
“Regrettably, Mr Morris did not receive the immediate treatment that his condition mandated … it demonstrates an indifference to Mr Morris’ proper care and elements of serious farce,” Mr Chandler said.
He recommended five changes to the Tasmanian Health Service, of which three have been adopted.
The THS had not informed him about the other two, which was for MRI results to be relayed immediately and for results to be discussed to determine if a patient should be transferred to another hospital prior to departing the LGH radiology department.
A THS spokesman said: “The Tasmanian Health Service takes every opportunity to review and improve patient care.”
“As the Coroner’s report itself identifies, the THS has already acknowledged the recommendations and acted on them.”