“Our stomachs are starting to get angry about what happened and how it happened,” said Holroyd, a former nurse.
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Smith ‘s death is one of four potentially preventable deaths discovered for Smith Herald investigation in which the coroner was not notified or chose not to investigate.
There was also no internal investigation, until two years later, the Health Claims Commission (HCCC) received an anonymous complaint.
A spokesman for the local health district in western NSW said that after making the complaint, Dubbo Hospital hired an independent surgeon from a tertiary hospital outside the LHD to review the case.
“This review found no deficiency in attention,” the spokesman said.
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The spokesman noted that Smith was not in charge of Dubbo Hospital when doctors decided his death was not reportable to the coroner, and those decisions were based on the criteria of the NSW Forensic Act.
These criteria indicate that deaths that “are not the reasonably expected outcome of a health-related procedure” should be reported.
He Herald was alerted to Smith’s death by whistleblowers dissatisfied with how it was handled.
He Herald contacted three senior surgeons from other parts of NSW, who agreed to review the case anonymously because they are not allowed to speak to the media.
Surgeons were also afraid of the repercussions of the NSW health bureaucracy, saying it punished doctors who talked about patient deaths and safety issues.
His comments echoed the condemnatory findings of a recent parliamentary inquiry, provoked by one Herald research. He raised “serious concerns about the governance of the health bureaucracy” and found hospital staff operating in a “culture of fear.”
Since then, NSW Health has insisted it has a fair culture, where staff are openly encouraged to report problems.
The surgeons were very critical of Smith’s care in Dubbo and were incredulous that local health districts chose not to investigate.
They argued that the case raised serious questions about whether regional hospitals like Dubbo had the right resources to recognize and intervene to save patients who were deteriorating as a result of the complications of surgery.
Surgeons said the fact that the research was commissioned by Dubbo Hospital and not by the HCCC raised broader questions about “self-regulation and lack of proper research.”
An HCCC spokeswoman said upon receiving the complaint that she “obtained important information from the Local Health District which generated more action by the LHD.”
He said the HCCC was still reviewing the material obtained as a result.
Gilgandra’s home
After the family and RPA doctors agreed that the most compassionate thing they could do was to stop treatment while keeping Heather Smith clinging to life, they told her she was going home to “Gil.”
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“She said it was wonderful,” Holroyd recalled. “When she woke up, I think she thought she was in Gil. And she died.
“She thought it was home.”
The Smith procedure, known as laparoscopic hiatus hernia repair with fundoplication, involves a mortality rate of 1% or less according to several studies, and perforation of the esophagus is an uncommon complication.
After surgery, Smith struggled to keep food low, suffering from nausea, pain and low blood pressure. He also developed a productive cough and was diagnosed with hospital-acquired pneumonia.
One doctor noted that it “looks miserable” and that it was “dry during my checkup.” She gathered enough to ask, with her tongue on her cheek, why there wasn’t The Bold and the Beautiful on TV.
One day Smith was experiencing “10 out of 10” pain, he refused to participate in mobility and breathing exercises with the physiotherapist. Smith received a “firm education” about the need for the exercises, according to records.
“Explanations of her poor recovery always put her in the basket, such as shortness of breath,” Holroyd recalled. “Something would never have gone wrong with his job.”
Holroyd becomes tearful when he remembers feeling powerless to challenge the staff, despite his nursing experience.
The board of honor at Dubbo Hospital is named after Holroyd after he completed his training there 40 years ago.
“It’s very sad to see the decline,” he said.
The spokesman said the local NSW health district offered its sincere condolences to the Smith family and pledged to reflect and make improvements whenever possible when patient outcomes or experiences do not meet expected standards. .
“Dubbo Hospital provides exceptional, high-quality care to thousands of people each year,” he said. “His team of health workers is attentive, professional and well-regarded.”
The rescue
Surgeons who reviewed the case for the Herald said the most important factor in determining the survival of a perforated esophagus was the time it took to detect and repair it, as the mortality rate increases. exponentially after the first 24 hours.
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“I don’t think any rural facility is suitable for repairing a perforated esophagus,” one added.
Surgeons said Smith’s death was a classic example of “rescue failure”: a delay in recognizing and responding to a patient’s deterioration after complications from surgery.
One of the surgeons interviewed by Herald explained that low-performing hospitals tend to lack large teams of experienced staff and specialists, well-equipped ICU facilities and 24-hour radiology coverage, which contribute to the diagnosis and treatment of complications.
A 2014 study by researchers at the University of NSW explored rescue failure rates by patient’s home address, in 153 local government areas in NSW.
Smith’s hometown, Gilgandra, was among the 31 LGAs identified as “hotspots” with high rates of rescue failure between 2002 and 2009.
One surgeon said patients who underwent hernia repair procedures usually return home after two nights. I would be “horrified” if a patient vomited and had severe pain on the 10th.
He believed that there should have been an investigation into root cause analysis.
“For RPA to say there was a hole that looked necrotic, there was a missed diagnosis.”
The surgeon said the case reflected the “Swiss cheese risk model” where several holes lined up to result in a bad result. He argued that hospitals needed an “adequate backup” when conducting difficult operations.
“Transferring someone from Dubbo to RPA is not a backup,” he said. “You need to have a couple of surgeons who have a specialized interest in this area available 24 hours a day to fix any problems.”
A spokesman for Western NSW LHD noted that Smith had been informed that he had “a higher risk of known surgical complications” because he was in the mid-1980s and living with serious and complex medical conditions and a history. This included medications that suppressed his immune system.
Surgeons also questioned the adequacy of patient selection.
“A healthy, fit patient who has a background application in Dubbo is one thing,” said another surgeon. “That lady was never that.”
A spokesman for the Western NSW LHD said decisions on whether patients would be transferred to tertiary facilities for surgery were made by doctors and treating specialists after extensive research and patient consultation.
The spokesman noted that the independent reviewer found that it was not necessary for Smith’s procedure to be performed in a tertiary hospital and, given his comorbidities, it was very unlikely that the outcome would be different if so.
The spokesman said the procedure was performed in the new surgical unit of Dubbo Hospital after the $ 306 million remodeling of the hospital and that during 2019-20 alone alone it performed more than 9,100 surgeries. .
‘Mistakes made’
Smith’s death bears striking resemblances to the death of another patient at Dubbo Hospital in 2010.
Kylie Greenaway’s small intestine was punctured during a hernia surgery. The staff took four days to move the 29-year-old to Sydney, where she died of sepsis.
Assistant coroner Hugh Dillon found that staff did not recognize the severity of some of Greenaway’s symptoms as appropriate action deteriorated and was delayed. They had “the decency to acknowledge that mistakes had been made and that Kylie had died as a result,” he said.
Two experts gave evidence that Greenaway should have been rushed to a high-volume hospital in Sydney once he developed sepsis.
Management told the investigation that the patient transport system would break down if this were a standard practice.
He Herald understands that the NSW coroner has also been investigating, after a patient deteriorated five weeks after surgery at Dubbo Hospital and was taken to RPA, where he died of sepsis.
A spokesman for Western NSW LHD said in a 2020 Office of Health Information survey, 96% of patients rated their care at Dubbo Hospital as “very good” or “good”.
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