Mathers, John William

“the motoreycle-Mr Kelley did not see the motorcycle. ~

_ motorcycle,

INQUEST CONCERNING THE DEATH

OF

JOHN WILLIAM MATHERS (dob 14 October 1976)

Id conceming the death of John Willlam Mathers. These mments that-relate to public health and safety and the: administration of justice. There has been @ lang delay in holding the inquest. | extend my sincere condolences to the family of John Mathers on their sad lass of their young, robust son. brother. father and friend. .

At about 11.15 am on Friday 12 December 2003, John Mathers was riding a black Kawasaki ZXR 600 motorcycle along Moss Street Slacks Creek, His front headlight was illuminated. A white Nova hatch-back sedan driven by Shaun Linsay Kelley was travelling from the opposite direction. The sedan executed a right hand tum across the path of Mr Mathers’ vehicle to enter commercial premises, The driver of a vehicle travelling behind Mr Kelley had a clear vision of

An inquest has been he are the findings and co!

Mr Mathers applied severe braking to avoid a collision. This is obvious from the

• observations of Mr Marment who saw the. motorcycle bouncing along the road

surface with the back wheel right off the road surface. Once the back wheel left the road surface, Mr Mathers lost control of the motarcycle, My Mathers and his motorcycle collided with the passengers side of the Nova hatch-back. Mr Mathers became airbome, landed on the road surface and slid for a distance along the road, His motorcycle also became airborne, landed on the road and slid along the road coming to rest between 10 and 20 metres away from Mr Mathers and a further distance away from the point of impact. :

The motorcycle sustained damage along the left hand side and to the top of the fuel tank. There is no obvious damage to the right hand side of the motorcycle.

The sedan sustained damage: along the left hand side in the vicinity of the rear door. The rear window was smashed, Black marks from the bike or-the helmet appear on the side of the sedan. A large dint is obvious in the roof of the sedan.

The dint in the roof seems of sirnilar configuration to the damaged fuel tank of the:

No forensic expert was engaged by the police to review the damage to both valiicles, the trajectory of both Mr Mathers and his bike, and the markings on the toad. Police witnesses indicated that experts may have been able to consider these facts and make determinatians about speed and other relevant contributing factors to the collision. Such evidence is not available to this inquest. Both vehicles ware found to be In satisfactory mechanical condition and no defects were found in elthar that may have contributed to the cause of the collision.

Police determined the evidence was not sufficient to charge Mr Kelley with any offence, criminal or traffic.

It is suggested that the reason Mr Kelley did not see the motorcycle was

a because the motorcycla was travelling at excessive speed so that it came upon him without waming. Mr Marment estimates the motorcycle was travelling at about 90 kph.

He heard the motor revving with a loud constant plich. Mr McClune saw the

motorcycle travelling reaily fast before it reached the collision scene and saw the motorcycle leaning right over as it came out of a bend like @ racing bike on a race track. Mr Braithwaite also formed the impression that the motorcycle was under heavy acceleration as it passed the imigation shop,

The evidence of Mr McClune, Mr Marment and Mr Braithwaite all rely on fleeting impressions of the motorcycle.” There is nothing to suggest thet any of these witnesses have any training or skill in estimating speed. {| accept that the motorcycle was loud and black and travelling at some speed. {do not accept Mr Marment’s estimate of speed as an accurate one. The evidence does not establish that Mr Mathers was speeding over the speed limit in that area.

Mr Marment first saw the motorcycle when it was 40 metres away. In the time Mr Marrnent travelled around the hatch-back the motorcycle had been under very heavy braking for some time. The motorcycle collided with the hatchback shortly after Mr. Marment travelled around the hatch-back to the left, The evidence as a whole does not support the proposition that Mr Kelley did not see the matorcycle because of speed. As.the vehicle travelling behind and slightly to the left of Mr Kelley did_see the motorcycle and as there was no other visual obstruction in the area, it would appear that the motorcycle was visibla from the position of Mr - Kelley. It would also appear that he did not see the motorcycle. .

Queensland Ambulance Service was called at 11.17am, They were on the scene and with Mr Mathers at 11.20am. They treated Mr Mathers with oxygen, bandages, compression bandages to his legs and a cervical collar. Mr Mathers was transported to Logan Hospital and arrived there at 12.10pm. His injuries

_ were considered and a decision made that it would be too dangerous to transport

him to a hospital better qualified to deal with the serious and dangerous trauma he had suffered. He was given X-rays and scans. He'was then in an unstable and serious condition. His injuries were severe and extensive. .

His injuries included a fractured pelvis, severe injuries to his left leg including a severed artery, a fractured pateila, an injury to his right knee, chest trauma with

' multiple abrasions and rib fractures, a punctured lung, a ruptured spleen, internal

bleeding, and a suspected head injury.

He went to the operating theatre at 1.45pm for an urgent laparotomy and exploration of his leg injuries. He had been diagnosed with a ruptured spleen and surgeons were concemed that they may need to amputate his leg. When a chest tube was inserted by anaesthetists at the commencement of the surgery a gush of’ air came out through the chest drain. The anaesthetist in charge determined that the Simms Level 1 infuser would not be used as he was aware of the dangers of using that machine without an air detector clamp. .

A safety warning had .been sent to the-shospital by the distributors of the equipment in November 2002. it wamed of dangers if the machine was used without the air detection clamp. There is a known medical risk of air embolism

'- with the use of the infuser due to the speed of the infusion when there is any _ Bccess for air. This risk also exists when manual pressure methods are used.

The instructions of Dr Federov were properly communicated to some staff. Other staff came to assist. ‘They. did nat know of the Instructions about the machine.

They used the machine. They had nat read the manual for the machine and they

ADA

were not adequately experienced in the use of the machine. !t was chaotic, noisy and stressful during surgery in view of the critieal condition of Mr Mathers at that

time.

Page 2 of the manual for the machine clearly states a warning that if specified waming procedures are not followed correctly, patient death may result, Page 11 of the manual has three such warnings — to remove all air fram salution bags, for the machine not to be used with commercia! |V solution bags less than 1 litre with alr, and for the machine not to be used with autotransfusion bags. The staff using the machine had not read these wamings. They had not been trained about these dangers. The manual for the machine includes laminated cards that are provided for attachment to the machine with the same three wamings. The laminated cards with the wamings were not attached to the machine. —

Air from saline bags was not removed. There is no evidence to factually prove that a half used bag was inserted into the machine. There is no evidence to factually prove that a bag was not replaced after it emptied. There is no evidence to factually prove the chain of events that lead to air haing seén by medical staff in the line connecting the machine to Mr Mathers. _ :

Surgeons performed surgery on Mr Mathers. His spleen was removed and several large laparotomy packs were applied to stem the significant bleeding. His condition had been improving during surgery but it suddenly deteriorated unexpectedly. Medical staff saw air in the line fram the infuser. The line was immediately shut off and proper emergency procedures followed to attempt to ‘resuscitate Mr Mathers. The procedures included inversion on the operating table, administration of adrenaline and atrophine and external cardiac massage.

Air was then aspirated from his. heart, intemal cardiac massage and direct intracardiac adrenaline were administered. All efforts failed to resuscitate him.

He suffered a cardiac arrest. He was pronounced dead at 3.25pm.

An autopsy was performed on 16 December. A past mortem examination certificate was issued stating that the cause of death was Air Embolus due to or as a consequence of Ruptured Spleen (Surgery) due to cr as a consequence of Motorcycle Accident (Rider). No evidence heard at the inquest calls into question those findings. | therefore make those findings as to what caused Mr Mathers to die. . . :

Medical opinion about the cause of the air embolism is divided. Dr Nankivell is of

s

the opinion that the embolism was caused by sir entering Mr Mathers’ lung that .

had been punctured by his broken ribs, He has presented emergency medical material to support his opinion. All athers doctors invoived in the surgery and the pathologist who conducted the autopsy prefer the diagnosis or opinion that the embolism was caused by air in the fine of the infuser entering Mr Mathers. It is possible that the embolism was caused by a-combination of factors.

The findings of the autopsy are consistent with air entering the blood circulation through an intravenous infusion pump. However the cause of the embollsm was not apperent at autopsy, The autopsy failed to discover a patent inter-ventricular septum in Mr Mather's heart. Only visual tests were applied to the inspection of his heart. A discovery of this defect would provide a medical explanation for the distribution of air in Mr Mathers brain at autopsy. {t would appear that the visual

tast at autopey may not be conclusive to determine the presence of such a defect In his heart.

It is clear that Mr Mathers sustained significant and life threatening injuries in the motorcycle collision. !t is also clear that ail medical staff Involved In his treatment applied a great deal of dedicated and diligent professional effort In treating him. It is also clear that every medical officer Involved in the treatment of Mr Mathers in the aperating theatre that day have been affected and traumatised by his demise.

The emotional impact upon them was evident as each gave evidence.

A number of factors after the collision [ed to his prospects for recovery being compromised. Medical evidence, particularly that of Dr Nankivell, point to a number of factors about the treatment received by Mr Mathers that warrant comment to be. made at the conclusion of this Inquest for consideration by the Honourable Minister for Queensland Heath and the Commisioner of the Queensland Ambulance Service that relate to public heath and safety and the administration of justica. | therefore make the fallowing comments: .

1. Mr Mathers waa transported by ambulance to the Logan Hospital. It

‘ “Was the nearest hospital. However he could have been taken to the Princess Alexandra Hospital which Is properly equipped and staffed fo deal with cases of significant emergency trauma. Mr Mathers chances of recovery would have been Improved with urgent medical treatment from a properly equipped emergency trauma hospital. When he arrived at Logan Hospital some time was spent assessing whether he was sufficiently stable to’ be transferred to Princess Alexandra Hospital.

With hindsight, his chances for full recovery would have been Improved if he had been taken directly to the Princess Ajexandra Hospital. It may therefore be appropriate for this case to be reviewed by Queensland Ambulance Service with a view to developing a protocol for the transport of patients suffering severe life threatening trauma to the nearest hospital with appropriate emergency trauma. services, rather then simply the nearest hospital.

2. It ls dear that at least two members of-staff used medical equipment,

; the Level 1 Infuser, without adequate training, without reading the - manual, without being aware of safety wamings, and withaut checking ° x with the supervising anaesthetist that i was appropriate for the device : to be used. It Is also clear that laminated wamings about the use of the devise were not atiached to the device as recommended by the

distributor of the device. Better policies and procedures seem: -

necessary to address these problems. Se

3. It is dear that the instructlons of the senior anaesthetist not to use the infuser was communicated to some but not all staff in the operating theatre, Better policies and procedures seam necessary to address this problem. ,

4. Or Nankivel gave evidence that 2 a surgeon with his experience and knowledge could have diagnosed the need for appropriate urgent surgery within seconds. There was a delay of more then an hour before he was consulted. He said in evidence he was eating his lunch while - Mr Mathers’ condition deteriorated. Thare would seem to be a need for be policies. and procedures on admission of critical eases in hospitals | not adequately equipped to deal with severe trauma cases for

_ the most sentor surgeon available to be immediately consutted.

A safety alert had baen fasued to the Logan Haapital about the use of the Infuser without an air detector clamp. The clamp had not been acquired by the haspital, i would appear that an audit of equipment currently used in public hospitals is needed to identify all equipment

. subject to safety alerts to ensure that wamings are attached to the

equipment or in appropriate cases for the equipment to be removed from use.

in view of the issued wamings and available information about the risks of the infuser, it would appear necessary to conduct an audit of all Level 1 Infusers in operations in Queensland public hospitals to ensure that the required air detection clamps are acquired and available for use.

‘The autopsy report was not sent to the hospital. It would appear that a .

formal process that ensured that an autopsy report be sent to the hospital concerned in cases of death during surgical procedures would benefit morbidity review. . ;

There was an unacceptable delay in the provision of staternents from medical staff to police’ investigators. It would appear that a better process could be adopted to prevent delays of the magnitude in this case.

The Gvidence heard in this case seems to suggest that tests other then visual tests may be needed to datarmine conclusively whether there is any patent inter-ventricular septum of the heart of patients who die from air embolus. :

In this case antemortem samples of admission blood were requested of the hospital ag part of the autopsy process. Those samples were not supplied, it would appear that a review of the processes involved in such requests may improve compliance with the requests by - pathologists conducting autopsies,

For Coronat’s Offfca Une:

File No!

Name of docenesd Combined Farm 20 & 28 , Version 1

QUEENSLAND CORONERS ACT 2003 (Sections 45, 48, 51 and 97(2))

RECORD OF CORONERS FINDINGS AND COMMENTS .

AND NOTICE OF COMPLETION OF CORONIAL INVESTIGATION

1 Si. CORNACK aR

(1 State coroner

{1 Deputy State Coroner

ml Coroner at BEENLEIGH (Couttiecaton) Telephone No. _ 38847500 have completed my Investigation and make the following findings/ findings and comments (Nate: carmments can culy be made when an inquest ls held). 7

A (1 Findings - Suspected Death (appicable any i a suspecies death & being investigated - ee section 45(1 )

find that the syapected death of {Name} {DO8)

St

(Residentia] Addreas) ~ 2 dis not happen OD didhappan {Nole: If the finding ls that the suspected death did not happen then Part B does nat have to be completed ~ age section 45(2} and (3). It the finding Is that the suspected death did happen then Part 8 must be completed.)

BJ Findings - Death (applicable where a death of suspected death has happened (see section 45(2) and (3) and whether or not an inquest is held) ; ; .

find about the death of:

Details about the deceased complete known cota): :

1. This is how the person died: oe ‘ A sedan tumed across the path of the m ridden by Mr Mathers. Despite heavy-brakir te collted Wi seden,

became alrhomn and fell to the roedway. He suffered serious and extensive injuries. He was transported to Logan Hospital where

he underwent Surgery to remove his ruptured spleen,

Whilst stil in theatre, he suffered an aromatic collapse and cardiac arrest us a sesuil of a massive air embolus, AM attempts fo ‘

fesuscitale Nim failed.

(print the circumstances of the death - section 45[2)(6))

2. Thisis when the person died: 3.25pm on 12 DECEMBER 2003 : (prin! when the perean died + sectton 45(2)(ol]

Combined Fonn 26 and 26 Version 4

For Coronar'a Olfica tise: File No: Name of decapead

3. Thit is where tha person died: _ LOGAN HOSPITAL, ARMETRONG ROAD, MEADOWEROOK OLD (heel where bie parson died seotion 45(21 (0) - ae ee ee ee ema, en Paes Had he users,

THe inpatnt rte reisain the ah

4. This ls what caused the person to dja: i(a) AIR EMBOLISM due to

_i(b) RUPTURED SPLEEN (Surgery)

1{c} MOTORCYCLE ACCIDENT (Rider) ; .

[print whet caused the pesan lo die = gection 45(2) (2) - this will a oes met have to be) thie medical causa of dati os Gleclosed by tho autopsy, .

wen

5. An inquast was nol held ; v An inquest was heldon 14 AUGUST & 9.10.11 OCTOBER 2008 at BEENLEIGH MAGISTRATES COURT ane

A Comments (epaicabye only if an inquest ie held = ston 46) Jam of the view that [7] tha death was not reasonably preventable .

(71 there are no procadura! or systemic reforms likely to reduce the occurrence af similar deaths (7) tha inquest has not raised any issues pertinent to public health or the administration of Justice, or Xx The lollowing comments are designed tp reduce the incidents of similar deaths {make tha following Comments (use altachments if necessary}:

1. Mr Mathers was transported by ambulance to the Logan Hospital. It was the nearest hospital. However he could have been taken to the Princess

• Alexandra Hospital which is properly equipped and staffed ta deal with cases of significant emergency trauma. Mr Mathers chances of recavery would have been improved with urgent medical treatment from 2 properly equipped emergency trauma hospital. When he arrived at Logan Hospital some time was spent assessing whether he was sufficiently stable to be transferred to Princess Alexandra Hospital. With hindsight, his chances for jut! recovery would have been improved if he had been taken directly to the Princess Alexandra Hospital. It may therefore be appropriate for this case to. be reviewed by Queensland Ambulance Service with a view to . developing a protocol ‘for the transport of patients suffering severe life threatening trauma to the nearest hospital with appropriate emergency trauma services, rather then simply the nearest hospital. :

2. It is clear that at least two members of staff used medica‘ equipment, the Level 1 Infuser, without adequate training, without feading the manual, without being aware of safety warnings, and without checking with the supervising anaesthetist that it was appropriate for the favice to be used.

It is also clear that laminated wamings about the use-of thetevise Were - not attached to the device as recommended by the distributor of the device, Better policies and procedures seem necessary to address these problems.

It is clear that the instructions of the senior anaesthetist not to use the infuser was communicated to some but not all staif.in the operating theatre, Better policies and procedures seem nevessary to address this problem.

Combined Form 20 and 28 Varaion 1

Page2 of 5

For Coranss's Offiog Usa: ” File No: : . Name of deceessd

4, Dr Nankivel gave evidence that a surgeon with his experience and knowledge could have diagnosed the need far appropriate urgent surgery within seconds. There was a delay of more then an hour before he was consulted. He said in evidence he was eating his lunch while Mr Mathers’ condition deteriorated, There would seem to be a need for better policies and procedures on admission of critical cases in hospitals not adequately equipped to deal with severe trauma cases for the most senior surgeon available to be immediately consulted.

5. A safety alert had been issued to the Logan Hospital about the use of the infuser without an air detector clamp. The clamp had not been acquired by the haspital. !t would appear that an audit of equipment currently used in public hospitals is needed to identify all equipment subject to safety alerts .to ensure that warnings are attached to the equipment or in appropriate cases for the equipment fo be removed from use. _

6. In view of the issued warnings and available information about the risks of the infuser, it would appear necessary to conduct an audit of all Level 4.

Infusers in operations in Queensland public hospitals to ensure that the required air detection clamps are acquired and available for use.

7. The autopsy répart was not sent to the hospital, It would appear that a formal process that ensured that an autopsy report be sent to the hospital concemed in cases of death during surgical procedures would benefit morbidity review. -

8. There was an unacceptable delay in the provision of statements from medical staff to police investigators. It would appear that a better procass could be adopted ta prevent delays of the magnitude in this case. -

9 The evidence heard In this case seems to suggest that tests other then visual tests may be needed to determine conclusively whether there is any - patent Inter-ventricular septum of the heart of patients who die from air embolus. _ . : :

10. in this case antemortem samples of admission blood were requested of the hospital as part of the aufopsy process. Thase samples were not supplied, It would appear that a review of the processes involved in such requests may improve compliance with the requests. by pathologists conducting autopsies.

B.

Date of Notice and of findings and comments Signature of person making the findings and comments: PI Copy of Combined Form 20 & 28 forwarded ta

(Note: Notve to Registrar. Birth Degihs and Manisga not requad {1 copy of Combined Fort 20 & 28 forwartled ta the Diatrict Officer OF Felice fer notification purposen

Forwarding of findings and cotmments (general):

These findings and comments (f appicaiva) have been given to: (ick anaroprinte baxes}

[2] The folowing tamily member who has Indicated thathe /she wil accept the document for the deceased person's emily Jeppicable whether or not an inquext ik heid « section 45/4} (8) and seotion 462) (2) of te Coroners Aci 2003),

Spouse (including de facto spouse); ; of Combined Font: 20 and 28 Version 1

For Coroner's Office Use:

Fila No: Namie of decensed . telephone: (1 asutt child because a spouse not reasunably available: af, . telephone: x Parent because a spause or aduft chikd not reasonably available: : ANNE COLLINS

of 52 THORNHILL DRIVE, GREENBANK QLD 4124 stetephone: 3297 5605

(C_ Aduitaibling because a spouse, adull child or parent not reasonably avallable:

of telephone:

(Nearest adult relative because a spouse, adult child, parent or adult sibling fs net reasonably avalable: of;

: telephone:

C1 ATS! amily member because the deceased was an ATIS person and spouse, aduft child, parent or adult sibving is fat, reasonably available: . : . — of.

• — . _ telephone: Oo ‘The Children’s Commissioner (only if the comments relate to the death of a chid. Applicabla purattant to section 46{2j(a) of the Coroners Act 2005). .

a forat name) : being a person with a sufficient interest who appeared at the inquest {applicable only where an inquest is hald = action 45/4) (b} ared scetion 48/21 {B} of the Coroners Act 2003), ° : fA] The State Coroner (ony sftme coroner is not the State Coranex, Applicable whether ar not an Inquest is held - section 45¢4) (c) of

ths Coronemn Act 2003} ° ; .

x _Hon Stephen Robertson being the Minister who administers the government entity Queensiand Health that deals with the matters to which ine comment relatos (appllasbe forint name of pavernment entity} onty if sn inquest - section 45{2) 16} of ths Coronara Act 2003),

_MrJim Higgins being the Commissioney of tha:

Qu: om that deals with the matters to which the comment relates (appicable ently if an inquatt ~ section 48{2){d) of tha Corgrars Act 2003)

Exira requirements far forwarding findings and comments ptappioatte) for deatis in care and deaths in custody feaction47 (2), These findings and comments (i appicabis} have also been given (0: (fick appropriate bowas) (The Attomey-General

Oo __. being the Minister wha administers:

(print tite of Minister) .

DD Foradeztin care, the: “ Po Residential Services (Accreditation) Act 2002 . .

Dleeblily Services Act 1892 Heath Services Ad! 1991 . ee Mental Hesith Act 2000 . .

Adoption of Children Act 1964 Cilid Protection Act 1999 C1) ss Feradeath in custany the: [1] Poca Powers and Respenstitas Act 2000 (_— Ceetive Seriioca Act 2000 Combined Fonn 20 and 28 Version t

DbDooooo

Pago 4 of 5

mo —_ . on

For Coronar’s OfiIca Une: File No: Nane of deceased

(1 Crime ened Mineonyed Act 2001 [1 esticos Act 1086 (A suventts Juatioa Act 1902 the chief executive officer of the: (print tte of chie? executive officer) Deparment in which the following Act is administered:

(print name of Departnnsrd) For a death in care, the: Residential Servioen (Accreditation) Att 2002 Disabity Services Act 1992 Hueith Sendces Aol 1891 "Mental Heath Aci 2000 Adoption of Chiidren Act 1964 Child Prataction Act 1999 a dealh in custody the: Polita Powars and Responsiblities Act 2000 Corrective Services Act 2000 Crime and Misconduct Act 2007 Jualces Act 1986 Juvenile Justice Act 1892 : .

Note: The combined Form 20 and 28 fs made pursuant to section 49(3) of the Acts Interpretation Act | 1954, :

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ooo00F? 000000

i Version 1 .

Combined Farm 20 and 28 Page 5 of 5