The death of a 65-year-old psychologist following kidney stone surgery at Calvary St Vincent's Hospital came after he was "belatedly" transferred to the hospital's high dependency unit, a coroner has found.
Subscribe now for unlimited access.
$0/
(min cost $0)
or signup to continue reading
The cause of Peter Golus's death on November 4, 2017, was a severe infection of the urinary tract.
He was described by his son Zachary as being in good health prior to his death, Coroner Simon Cooper said in his findings into Dr Golus's death.
IN OTHER NEWS:
The surgery on November 3, conducted by urologist Robert Jensen, appeared to be successful. Dr Jensen did not observe any obvious infection in Dr Golus's urinary tract at the time of the procedure.
After the surgery, Dr Golus was returned to the ward at 5.50pm. His vital signs were observed as being stable and medical notes indicated he was alert and declined pain relief at 6pm.
But at 7pm, his temperature was rising and a phone call was made to Dr Jensen, who ordered blood cultures and a urine sample to be taken.
The patient was complaining of abdominal pain by 1.30am.
Dr Golus's condition continued to worsen as the morning wore on. Nursing staff contacted Dr Jensen about 2am after the patient's manual blood pressure had been recorded as low (84/60).
Dr Jensen ordered saline to be given to Dr Golus. He was also administered 10 milligrams of morphine at 2.25 am to help with his lower abdominal pain.
Mr Cooper said Dr Golus's blood pressure was observed as being at a "dangerously low" level of 60/40 at 2.50am.
Dr Jensen instructed nursing staff to record observations of Dr Golus every five minutes, but Mr Cooper said this would have been better carried out in the hospital's high dependency ward.
Mr Cooper noted that observations couldn't be carried out on the ward Dr Golus remained on either, due to staff-to-patient ratios being "comparable" to those in the high dependency unit.
"At 6.45am, upon review of his overnight history, a decision was made by the St Vincent's Hospital morning shift coordinator for Dr Golus to be moved, belatedly in my view, to the hospital's high dependency unit," he said.
By 8.20am, Dr Golus was unresponsive. He was transferred to the Launceston General Hospital but couldn't be revived and was pronounced dead about 10.15am.
A decision was made by the St Vincent's Hospital morning shift coordinator for Dr Golus to be moved, belatedly in my view, to the hospital's high dependency unit.
- Simon Cooper, Coroner
AJ Bell, a medical adviser to the coroner, reported that it was likely Dr Golus had developed septic shock by 2am on November 4.
"Dr Bell ... noted that the medical records make it clear that Dr Golus' vital signs were recorded at 2.50am and then not again for 3 1/2 hours. I note, as pointed out above, this was despite an express direction (and patent need) for much more frequent observations," Mr Cooper said.
