An Inquest taken on behalf of our Sovereign Lady the Queen at  in the State of South Australia, on the , before , a Coroner for the said State, concerning the death of Edward Sydney Hobby.

1. Background

1.1 Edward Sydney Hobby was born on 3 May 1918. In April 1996 he lived at the Residential Care Units operated by the Blind Welfare Association at 1 Cameron Avenue, Gilles Plains. Mr. Hobby was blind, as a result of glaucoma.

1.2 He was described as a very independent man who was quite mobile about the complex of units. The Residential Coordinator, Ms. D.A. Hamilton, said:-

"Mr. Hobby was a very independent person who strongly guarded his privacy and independence. He was mentally alert, if at times a little forgetful and, with the limits of his disability, he stayed in charge of his

own life and all staff respected that. Had Ed wished for any medical intervention (he always contacted the doctor himself), he would have done so independently".

(Exhibit C.4a, p2)

2. Circumstances of Mr. Hobby’s injury

2.1 Mr. Hobby told his daughter, Ms. W.M. Mainwaring, that "about three or four weeks earlier he had walked into an outside canvas awning blind where he lives and had minor pain since then around his stomach" (see her statement, Exhibit C.1a). This conversation occurred on 15 April 1996.

2.2 Ms. Hamilton said that Mr. Hobby also spoke to her about the incident, which he said occurred on or about 30 March 1996. He told her that he was unhurt and had no wish to see a doctor (Exhibit C.4a, p1).

2.3 Ms. Hamilton said that the awning had subsequently been fixed. The awnings were described by the handyman at the Centre, Mr. J.C. McCormick, as follows:-

"The residential care complex includes a two-storey building. Unit 21 is located on the upper floor. Along the upper and lower sections there are a number of large outdoor blinds fitted. These are the type that can be rolled up or down by rope and have to be tied off and secured at the desired height. The blinds on the upper level have leather straps fitted to the bottom which can be used to fasten the blinds to metal loops fitted to the balcony railings. Otherwise they hang freely and are not fitted to any type of frame. They have a large weighted beam in the bottom. The blinds were fitted well before I worked at the complex and during the period I worked with Tony Davies, he told me there was no need to put the blinds up and down.

 

Residents can request that the blinds in front of their units can be raised or lowered. Once I lowered a blind for the occupant of unit 24 but other than that I have never lowered any of the other blinds. The blinds are normally rolled up and therefore have remained in good condition. They are not checked by me for serviceability unless I use them. Residents can lower their own blinds if they are able or they can have visitors lower them".

(Exhibit C.5a, p2)

The awnings have since been removed and Mr. McCormick said that "at this stage (they) are not going to be replaced".

2.4 Unfortunately, prior to Mr. Hobby’s death, Mr. McCormick did not keep any records of his maintenance work from which the dates of any remedial work can be confirmed. He said that he now does so (see Exhibit C.5a, p3), and this would seem to be a wise practice.

3. Events of Sunday 14 August 1996

3.1 Mr. Hobby consulted a locum, Dr. G.W. Mussared, on 14 April 1996 complaining of pain in the right upper quadrant of his abdomen of increasing intensity over the previous three days. He reported having vomited twice in that time. Dr. Mussared noted tenderness in the area covering three to four inches. He referred Mr. Hobby to Modbury Hospital with right upper quadrant abdominal pain for investigation, and suggested possible diagnoses of diverticulitis or cholecystitis.

3.2 Mr. Hobby was seen at Modbury Hospital, initially by Dr. J.M. Dennis, a casual Medical Officer in the Emergency Department at Modbury Hospital. Unfortunately, Dr. Mussared’s referral letter (Exhibit C.12) was not available then. Dr. Dennis denied having seen it before (Exhibit C.7a, p2), and it was located in the Nursing Home file, not the Modbury Hospital casenotes. It is not clear how this came about, but it is clearly unsatisfactory that a potentially important piece of evidence was apparently not produced to the hospital, or if it was, it was not retained.

3.3 Mr. Hobby was taken to Modbury Hospital by ambulance. The ambulance officer’s report is present in the casenotes (Exhibit C.8), and records that:-

"This 77 year old man had gradual onset of abdominal pain this morning. Nil vomit. Nil diarrhoea.

...

Mild abdominal pain since early morning at level of umbilicus radiating across abdominal area.

BP 120 palpable. Pulse irregular 70 BPM.

...

Swelling noted to abdominal area. Pain on palpation. Patient rates pain at 6 out of 10. Previous doctor’s letter with patient".

 

The contradictions between that note and the history elicited by Dr. Dennis upon arrival at Modbury Hospital will become obvious.

3.4 At about 8.30p.m. Mr. Hobby was seen by Dr. Dennis. Understandably, Dr. Dennis had no specific recall of Mr. Hobby’s case, and relied completely on the casenotes in relating his involvement (see Exhibit C.7a, p2).

3.5 Mr. Hobby told Dr. Dennis that he had been having pain for three days. He also reported vomiting about 24 hours earlier (p.4). Dr. Dennis found him to be moderately tender in the right upper quadrant, and he also noticed some voluntary guarding and rebound tenderness (Exhibit C.7a, p5). Dr. Dennis ordered a number of tests, including chest and abdominal X-rays, and blood tests, and then called in the Surgical Registrar, Dr. K.A. Edyvane, for review.

3.6 Mr. Hobby was reviewed by Dr. Edyvane at about 10.00p.m. She said that she was about to leave the hospital after a long day (Exhibit C.9, p2). She said that she would have seen the X-rays, but the results from the blood tests would not have been available. Dr. Edyvane said that Mr. Hobby told her that he "felt quite well", and that he did not know why he was in hospital (T.44). She said that he seemed quite relaxed, that he was not in pain, and that he had felt that the locum had over-reacted (T.46). He showed her the bruises on his abdomen, both of which she described as being the size of a 50 cent piece. The bruises were near the costal margin, below the bottom rib. Dr. Edyvane found no generalised tenderness, and no guarding. He was tachycardic (fast pulse rate), although she did not note the rate (T.47). She said that she did not test for rebound tenderness, saying that such a sign was difficult to elicit in the elderly, who often confused the questions associated with the test (T.49). She preferred percussion tests, which did not demonstrate peritoneal irritation on this occasion. She told me that she tested Mr. Hobby’s abdomen very carefully, and palpated it quite deeply, and did not demonstrate tenderness anywhere apart from the general area of the bruises (T.48). I find this evidence odd in view of the evidence of Doctors Mussared and Dennis and that of the ambulance officer, all of whom found tenderness. I will discuss this issue again later.

3.7 In relation to the chest X-rays, Dr. Edyvane said that she considered them "normal" for a 77 year old man (T.53). She was not then in possession of the radiologist’s report, which noted the presence of atelectasis (lung collapse). The radiologist also noted a "little" elevation of the right hemi-diaphragm.

3.8 When giving evidence, Dr. Edyvane described the atelectasis as "minor" (T.55). She said that she did not see the elevation of the hemi-diaphragm, conceding that it was an "important sign for an inter-abdominal catastrophe" (T.56).

3.9 Dr. Edyvane said that she found nothing in the history of the condition, nor upon examination of Mr. Hobby, or in the X-rays, to indicate that he had a major abdominal problem which indicated that further treatment was necessary. She said that she was happy for Mr. Hobby to be discharged provided that the blood tests were "chased" (T.60). She instructed Dr. Dennis to this effect.

3.10 Dr. Edyvane acknowledged at the inquest that in doing so, she did not give clear enough instructions to Dr. Dennis. She relied upon him to make an appraisal of the blood test results and form his own judgment about whether Mr. Hobby required further treatment. She acknowledged that she should have told Dr. Dennis that he should call her if Mr. Hobby’s white cell count was over 12, and that he should not have been discharged until that had occurred. She said that if this had occurred, she would have discussed his case with the consultant the following day, with a view to further investigation, perhaps in the form of a CT scan (T.64). She would not have discharged Mr. Hobby that night had she been aware of these results (T.69).

3.11 In the absence of the radiologist’s report and blood test results, Dr. Edyvane authorised the discharge of the patient. Her diagnosis appears in the casenotes as:-

"D: soft tissue injury

Now recalls bumping into a blind during a storm 3/7 ago - injuring RUQ (right upper quadrant).

P: D/C (discharge)

- need GP review re á BP (blood pressure), and á HR (heart rate) and orthopnoea".

 

3.12 In view of that, Dr. Dennis discharged Mr. Hobby at about 10.30p.m. on 14 April 1996. He wrote a letter to Dr. Ong, saying, in part:-

"... Blood was taken but results are not yet available - could you please check with Gribbles".

 

In view of Dr. Edyvane’s diagnosis, Dr. Dennis said that he did not regard follow up of the blood tests as urgent (Exhibit C.7a, p13).

3.13 When the blood test results did come in, Dr. Dennis noted the elevated white cell levels. He tried to call Dr. Ong, but was put through to a locum, and was told that she would "chase up" the issue (see Dr. Dennis’ entry in the casenotes).

3.14 In fact, the blood tests disclosed significant cause for concern. In particular, Mr. Hobby’s white cell count was very high at 18.2. Dr. Edyvane acknowledged that these results warranted further investigation of Mr. Hobby’s condition, particularly into whether he had suffered internal trauma, or an inflammatory or infective condition such as peritonitis (T.62). Had a CT scan been performed on the basis of these test results, it may well have demonstrated the presence of fluid in the peritoneal cavity and thus a laparotomy would have been indicated.

4. Events of 16 April 1996

4.1 The pain in Mr. Hobby’s abdomen apparently continued, to the extent that, two days later, he was transported back to the Modbury Hospital, where he was seen in the Emergency Department by Dr. Markwick at about 8.50a.m. Mr. Hobby still had Dr. Dennis’ discharge letter with him. Dr. Markwick initiated X-rays, blood tests and other investigations. He also requested a surgical review at around 11.00a.m.

4.2 At about 4.30p.m. Mr. Hobby was seen by Dr. Michael Chin, Surgical Registrar. Dr. Chin examined Mr. Hobby and, like Dr. Edyvane, found no rebound tenderness, guarding or tenderness upon percussion (these signs had been elicited by Dr. Markwick) (T.10).

4.3 The blood tests taken earlier that day indicated that the white cell count had come down to 12.4. This, and other indicators, were more optimistic than the readings taken on 14 April. Dr. Chin also noted an increase in the levels of urea and creatinine in the serum biochemistry, which he suggested may have indicated a deterioration in kidney function (T.13). He said that the increase in the bilirubin level in the liver function test suggested Gilberts Syndrome, hepatitis, a tumour, or a bile duct obstruction from gallstones.

4.4 An abdominal ultrasound arranged by Dr. Markwick reported that the liver was normal, there was a small polyp in the gallbladder which was otherwise clear, and that there was a "moderate amount of intra-abdominal ascites" (fluid in the peritoneal cavity) (T.20).

4.5 Dr. Chin admitted Mr. Hobby to hospital, and referred him to the medical team in case he was developing liver failure, and possibly kidney failure as well (T.24). Like Dr. Edyvane, Dr. Chin did not consider that Mr. Hobby was showing signs of peritonitis and, again like her, felt that his abdominal symptoms were merely a resolving abdominal soft tissue injury.

4.6 Mr. Hobby was seen by a Dr. Beckinsale, a medical intern, at 11.50p.m. that night. Her entry in the casenotes indicates that she elicited symptoms of abdominal pain which were not apparent to Dr. Chin (T.25). She noted a sharp pain going through to the back and in a band across the central abdomen. The abdomen was tender, distended, and soft, with "full flanks". She also noted "shifting dullness" and tenderness on percussion.

4.7 Dr. Beckinsale referred Mr. Hobby for review by the "home team" the next day (17 April 1996). She noted at the time that the notes of Doctors Markwick, Chin and the medical registrar were not to be found in the casenotes, so she was unaware, except in the barest detail, of what had transpired earlier in the admission. This standard of note-keeping was the subject of trenchant criticism, which I will discuss later in the findings.

4.8 Little further in the way of intervention occurred during 17 April 1996. Mr. Hobby was reviewed by a Dr. Grill in the afternoon, and at about 8.00p.m. he was noted to have vomited "coffee grounds", suggesting the presence of blood. He was observed on subsequent occasions to be developing kidney and heart failure. His condition deteriorated until he suffered a cardiac arrest early in the morning of 18 April 1996. The casenotes record that he was pronounced deceased at 7.55a.m.

5. Cause of death

5.1 A post mortem examination of the body of the deceased was performed by Dr. R.A. James, forensic pathologist, on 19 April 1996. Dr. James found that the cause of death was "biliary peritonitis complicating traumatic perforation of the gall bladder".

5.2 Dr. James noted two areas of fading blue/brown bruises, each approximately 2cm across, on the skin of the right upper abdominal quadrant. He commented:-

"The clinical history suggests that the deceased was struck by a blind approximately 3 weeks before his death. This was followed by abdominal pain prior to his admission to Modbury Hospital on 16/4/96. Post mortem examination has shown established peritonitis. The basis for his peritonitis appears to be the perforation of the ball bladder. Gall bladder perforation is unusual unless associated with gallstones or other natural disease. The bruising on the abdominal wall overlying the gall bladder and the bruising on the serosa of the gall bladder itself is consistent with an earlier traumatic incident to the right upper abdominal quadrant. The clinical blindness might have allowed the unusual injury to occur on the unprotected abdomen. The rather long clinical period since the alleged incident is explicable on the basis of protection of the injured gall bladder wall by sealing it against the adjacent overlying liver. The appearances of biliary peritonitis reflect free bile within the abdominal cavity".

(Exhibit C.3a, p3)

6. Quality of treatment

6.1 The treatment given to Mr. Hobby was reviewed by Dr. David Shearman, formerly Professor of Medicine at the Royal Adelaide Hospital, and now a Consultant Physician and Gastro-enterologist. Dr. Shearman made a number of comments about the course of treatment administered, and these can be summarised as follows:-

 

• the bile that leaked through the perforation in Mr. Hobby’s gallbladder was sterile (since he did not have an infection). The peritonitis was therefore an inflammatory response, not a bacterial infection which would have led to fever, septicaemia, etc. Mr. Hobby’s was a rarer condition, and comprises less than ten percent of cases of peritonitis (T.101). This explains why the onset of Mr. Hobby’s illness was slower, and the signs less obvious (T.96);

• the symptoms of peritonitis displayed by Mr. Hobby included abdominal pain, vomiting, tenderness, raised hemi-diaphragm, atelectasis, raised white cell count, abnormal renal function (raised urea and creatinine levels), abnormal liver function (raised bilirubin level), and cardio-vascular stress (raised pulse rate, raised blood pressure, and breathlessness when lying) (T.100);

• it is unlikely that the symptoms would have come and gone while Mr. Hobby was in hospital, but it is not surprising that there were discrepancies in the results of examination (e.g. between Doctors Dennis and Edyvane) (T.102);

• the abdominal and chest X-rays taken on 14 April 1996 were not normal - the raised right hemi-diaphragm was a "very important sign" indicating a problem in the abdomen. The atelectasis was only small, but these signs taken together were important (T.104);

• a surgical registrar of some experience (Dr. Edyvane had three years experience) should have been concerned with these X-rays (T.105);

• it was inappropriate to discharge Mr. Hobby from hospital before the results of the blood test were known (T.106). The G.P. had referred the patient to a teaching hospital for investigation. It was the role of the teaching hospital to check the blood test results, form a diagnosis and then treat the patient (T.109). It was "unacceptable" that the patient was referred back to the G.P. with a request that the G.P. review the blood test results (Exhibit C.11, p2);

• the symptoms would not have allowed a specific diagnosis of a perforated gallbladder, but rather a diagnosis of "acute abdomen", an emergency situation requiring immediate investigation (T.107);

• the situation was not helped by the standard of note-keeping, particularly during the 16 April admission, which Dr. Shearman described as "woefully inadequate" (Exhibit C.11, p3). This is an important issue, since proper note-keeping enables subsequent clinicians to build a picture cumulatively, and enables them to tell at a glance what remains to be done (p.4);

• when Mr. Hobby returned to hospital on 16 April, the results of the further blood tests were still abnormal, and although the leucocyte level was better than it had been, the renal and liver function indicators had deteriorated significantly (T.111);

• it is surprising that Mr. Hobby was not seen by a consultant during either of his visits to Modbury Hospital until just before he died (T.112);

• by the time he began vomiting during the evening of 17 April, his chances of survival had become much worse (T.113);

• Mr. Hobby should have been operated upon during the morning of 16 April. There was a "window of opportunity" in the first 24 hours of his admission. Instead, he received no definitive treatment "until he vomited blood 36 hours later". There was sufficient evidence to involve a consultant on an urgent basis long before that (T.113-114);

• if Mr. Hobby had been treated surgically at the appropriate time (early on 16 April 1996), he had a "reasonable chance of survival" (T.110), particularly in view of the fact that the post mortem report showed that he had a "remarkably healthy vascular system" (Exhibit C.11, p5).

 

7. Conclusion

7.1 I think it is unnecessary to do more than quote Dr. Shearman’s conclusion in his report:-

"I believe that this patient died from inadequate medical and surgical management particularly surgical. It has to be recognised that in bile peritonitis, large quantities of sterile bile can accumulate before dramatic physical signs are produced. The signs are often minimal in the elderly. Nevertheless to those trained in the management of acute abdominal emergencies, there were many symptoms and signs which should have led to a consideration of an intra-abdominal catastrophe. The events were compounded by inadequate administration (loss of notes), inadequate documentation, possibly superficial examination, failure to review investigations in their entirety and probably lack of knowledge as to the condition of biliary peritonitis and how it presents. It appears that there was no consultant input for two working days and until such time as it was too late to save the patient. In fact I can see no documentation that the patient was seen by any consultant until a few minutes before his death on 18.4.96.

 

This patient was obviously a fit alert 80 year old and as the post-mortem showed, he had a remarkably healthy vascular system. Had he been treated surgically at the appropriate time, the chances are that he would have survived".

(Exhibit C.11, p4-5)

7.2 I accept Dr. Shearman’s opinion (indeed it was not seriously contested), and find that the treatment accorded to Mr. Hobby was inadequate for the reasons he has given.

8. Recommendations

8.1 In view of the conclusions I have reached, I am of the opinion that it is appropriate to make recommendations pursuant to Section 25(2) of the Coroners Act, since to do so may "prevent, or reduce the unlikelihood of, a recurrence of an event similar to the event that was the subject of the inquest". I recommend that:-

all of the medical officers involved in this case should review their practices in an attempt to ensure that patients with serious and potentially life-threatening conditions receive appropriate and timely treatment;

hospital and medical administrators consider how systems might be reviewed with a view to ensuring that patients with serious and potentially life-threatening conditions are reviewed at an early stage of their treatment by appropriately trained and preferably consultant medical officers.

 

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