The death of a devoted family man who developed sepsis after surgery at Launceston General Hospital was entirely avoidable and the result of poor medical treatment, a coroner has found.
Dilston man Graeme Charles Davis died in January 2018 - almost two weeks after undergoing surgery in response to a rare type of bladder cancer, known as squamous cell carcinoma.
Coroner Simon Cooper handed down his findings into Mr Davis' death on Thursday - a death that was only investigated after his widow, Patricia Davis, reported his treatment to the Office of the Health Complaints Commissioner.
Events leading up to death
The 56-year-old was admitted to the LGH on January 11 to undergo an operation to remove his bladder, form an ileal conduit and dissect the surrounding lymph nodes.
Coroner Cooper noted the surgery proceeded without incident.
However, on the morning of January 16, Mr Davis suffered nausea, vomiting and abdominal pain.
"From then on Mr Davis' condition worsened," the report reads.
Over the coming days, Coroner Cooper noted Mr Davis' abdominal wound was draining fluid, with medical notes describing it as "appearing bad".
While given a single dose of antibiotics and his medical notes describing the wound as acceptable, Coroner Cooper noted Mr Davis' "abdomen was distended, his white blood count elevated and his C reactive protein at 205 mg/L strongly suggestive of a bacterial infection".
"No antibiotics were administered, although Mr Davis' medical records note that the issue of antibiotics was to be discussed the 'next day'."
However, Coroner Cooper said antibiotics were not administered the next day, "seemingly because the urology team appeared to think Mr Davis' wound was not infected".
"Antibiotics were not commenced the following day either, even though Mr Davis' white blood cell count had risen, albumen level had fallen and his CRP remained elevated."
By January 25, planning for Mr Davis' discharge from hospital commenced.
"However, as the day wore on it became apparent he had a urinary tract infection with fever, increased white blood cell count elevation, high CRP and a positive urine culture."
Antibiotics were commenced intravenously, but at 10.25pm that day a code blue was called after Mr Davis suffered a "period of unconsciousness" while on the toilet.
"Later still, his antibiotic therapy was changed and further blood cultures taken," Coroner Cooper notes.
The next day on January 26, Dr Davis was reviewed by a urology registrar, who noted a diagnosis of urosepsis.
By that afternoon his condition continued to deteriorate.
"It is apparent by then Mr Davis was gravely ill," Coroner Cooper said.
"It seems from his medical records that the previously ordered antibiotic therapy was administered some four hours late. The records record a note to "look out for blood culture sensitivities".
However, Coroner Cooper found no change was made to his treatment, he continued to deteriorate, suffered a cardiac arrest and died shortly after midnight on January 27.
Investigation and conclusions
Mr Davis' death was not initially reported to the Coroner, with the cause of death initially determined as a pulmonary embolism.
However, as a result of a post-mortem, no evidence of pulmonary embolism was found.
An investigation into Mr Davis' treatment and death was reviewed by Dr A Bell, the Medical Advisor to the Coronial Division.
In his report, Dr Bell said the failure to administer appropriate antibiotics at the appropriate times was an "unacceptable level of practice".
Dr Bell also noted a failure to diagnose the site of the sepsis and a failure to appreciate its severity led to a preventable death.
Coroner Cooper concluded Mr Davis received antibiotics "too late", with the view that his death was entirely avoidable, and caused by poor medical treatment.
His findings were sent in draft to the LGH, however, he said "no issue was taken in relation to any aspect of them".
No recommendations were made.
"I convey my sincere condolences to the family and loved ones of Graeme Charles Davis," Coroner Cooper said.
The Health Department has been contacted for comment.
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