Coroner's Finding: McManus, Pamela

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Rod Chandler, Coroner, having investigated the death of Pamela McManus Find:

(a) The identity of the deceased is Pamela McManus.

(b) Mrs McManus was born in Hobart on 8 February 1937 and was aged 75 years.

(c) Mrs McManus died at the Royal Hobart Hospital (‘the RHH’) in Hobart on 15 September 2012.

(d) The cause of Mrs McManus’ death was a large volume aspiration that developed following right hemicolectomy for adenocarcinoma of the colon.

Background: Mrs McManus was a widow and the mother of two daughters. She was an active playwright and resided at 16 Hawthorn Drive in Kingston. Her medical history included cervical cancer in 2002, a benign small bowel mesenteric tumour, idiopathic retroperitoneal fibrosis, incisional abdominal hernias, hypertension, dyslipidaemia, lymph oedema and vitamin B12 and iron deficiency secondary to short bowel syndrome. Dr Keith Loxton of the John Street Medical Centre was Mrs McManus’ long-term general medical practitioner.

Circumstances Surrounding the Death: Mrs McManus was taken to the RHH by ambulance on 10 August 2012 after being discovered on the floor of her kitchen by a relative. She was examined in the Emergency Department. (‘ED’). It was believed that she had had a syncopal episode (a faint), that she was anaemic, that she had some renal impairment and that she was not coping particularly well at home alone. She was admitted to a medical ward and then later transferred to the Peacock Ward for rehabilitation and further care. On 28 August Mrs McManus underwent a colonoscopy and a gastroscopy. Biopsies were taken. Three days later she was informed that the biopsies indicated that she had a carcinoma of the bowel in the area of the hepatic flexure.

On 13 September Mrs McManus underwent surgery in the form of a right open hemicolectomy. The surgeon was Dr Srinivasa Yellapu. Over the following days she developed some agitation and hallucinations but was making a steady recovery with small oral intake and stable clinical observations.

On 15 September Mrs McManus was reviewed by her surgical team. They authorised the removal of her thoracic epidural, central venous catheter and indwelling catheter. They directed that she be commenced on oral analgesia. Shortly after this, nursing staff were

assisting Mrs McManus to mobilise from her bed to her chair when she suffered a cardiac arrest. A MET call was placed. However, in line with Mrs McManus’ goals of care, resuscitation attempts were not commenced and she died.

Post-Mortem Examination: This was carried out by Forensic Pathologist, Dr Donald Ritchey. He reports that in his view the cause of Mrs McManus’ death was a large volume aspiration that developed following a right hemicolectomy for adenocarcinoma of the colon. I accept this opinion.

Investigation: Dr A J Bell is retained as a medical adviser to the coroner. He advises me that, in his opinion, the surgery undertaken by Mr Yellapu at the RHH was necessary as a lifesaving procedure. He further advises that, in his view, Mrs McManus’ post-operative care and management by the RHH was sound and that there were no clues in the preceding days to alert clinicians to her imminent death. I accept these opinions.

As a consequence of concerns expressed by Ms Bridget McManus, the eldest daughter of Mrs McManus, a focus of this investigation has been upon Mrs McManus’ medical care, both by Dr Loxton and by the RHH, prior to her diagnosis of a carcinoma of the bowel made in late August 2012. That investigation has revealed the following chronology of events:  During late 2010 and the first half of 2011 Mrs McManus was reviewed monthly by Dr Loxton. The reviews concerned vitamin B12 administration and on occasions treatment for a cough. Specifically, on 18 April 2011 Dr Loxton described Mrs McManus as being pale and pasty. She was given a further Vitamin B12 injection on that date.

 On 27 June 2011 Mrs McManus was reviewed by Dr K Hansford, a general practitioner employed in Dr Loxton’s practice. He described Mrs McManus as being fatigued. He ordered blood tests including thyroid function tests, a full blood examination and iron studies. When the results were received at the practice an urgent appointment was made for Mrs McManus.

 On 14 July 2011 Mrs McManus was seen by Dr Martin Ward of the John Street Medical Centre. He recorded a heart rate of 130 bpm and blood pressure of 110/70 mmHg. The full blood examination revealed haemoglobin of 71g/L (compared to a normal level of 116/165g/L) with an iron deficiency picture on the blood film, the mean corpuscular volume (MCV) was 83 fL/cell (normal 80 to 100 fL/cell). The notes from the Medical Centre show that a letter was written by Dr Ward to the RHH referring Mrs McManus for an urgent opinion. Her blood test results were included with the referral letter. At the same consultation Dr Ward determined to treat Mrs McManus with iron and folate medication and to continue her Vitamin B12 injections.

 From July 2011 Dr Loxton reviewed Mrs McManus monthly for the next 3 months.

The Vitamin B12 injections and oral iron medications were maintained.

 On 7 November 2011 a blood test showed haemoglobin of 66g/L, again of an iron deficient type with a low MCV typical of iron deficiency anaemia.

 On 14 November 2011 Dr Loxton recorded that an appointment had not been made with the RHH.

 Beginning January 2012 Dr Loxton continued to review Mrs McManus on a monthly basis for the next 8 months. On 29 May he noted Mrs McManus to be “very poorly” and short of breath. An ECG at this time was reported as essentially normal.

 A visit on 25 June was described as being unremarkable.

 On 9 July Dr Loxton noted Mrs McManus to be “very poorly – malaise, oedema L leg” and short of breath. He recorded a diagnosis of anaemia.

 On 6 August Dr Loxton noted Mrs McManus to be “very poorly.” It was at about this time that a request was made of Dr Loxton by Ms Bridget McManus for her mother to be admitted to hospital. However, he resisted believing that Mrs McManus was in need of nursing home care.

 It was on 10 August that Mrs McManus was discovered on the floor at her home and was then conveyed by ambulance to the ED at the RHH.

 Investigations in the ED showed Mrs McManus to be anaemic with some renal impairment, her white cell count was 15.8, neutrophils were 14.9, her CRP was 58.4 and her clotting profile slightly abnormal. Mrs McManus was admitted to a medical ward and her management thereafter has been summarised by me earlier in these findings. However, it is necessary for me to note the following particular matters:  On 11 August Mrs McManus was seen by Staff Specialist, Dr Janet Vial.

She believed the diagnosis to be anaemia secondary to malabsorption.

She requested a further blood transfusion. On 14 August the same diagnosis was repeated. Two days later a diagnosis of malabsorption anaemia corrected by blood transfusion was made. It was at this point that Mrs McManus was transferred to the rehabilitation ward.

 Whilst in the rehabilitation ward Mrs McManus continued to have persistent anaemia and iron deficiency. A CT scan of the chest, abdomen and pelvis was then organised for 23 August. It revealed multiple small bilateral pulmonary nodules and extensive thickening of the wall of the ascending colon with adjacent enlarged lymph nodes. Five days later Mrs McManus underwent the colonoscopy and gastroscopy which led to Mrs McManus’ diagnosis of colonic cancer at the level of the hepatic flexure.

As part of the investigation a report was sought from Dr Vial. She has made these comments: “Although I considered the possibility that (Mrs McManus’) anaemia and bowel symptoms might be contributed to by a problem such as bowel cancer (we measured faecal occult blood, considered colonoscopy) my experience with patients of her poor functional status is that if such a diagnosis is made they are very unlikely to be able to tolerate or benefit from definitive treatment such as surgery or chemotherapy.

Therefore I considered that aggressive pursuit of such a diagnosis was not necessarily, in the patients best interests. In my opinion the best approach in terms of optimum quality of life for such a patient would be a palliative approach i.e. symptom management plus ensuring that daily care needs were adequately met.” “The reasons Mrs McManus was referred to rehabilitation would have been to see if it was possible to improve her function enough to return home with support or failing that maximise her function to optimise her quality of life in a nursing home.”

“If the patient made spectacular gains in terms of function and nutritional status during rehabilitation then it may have been appropriate to re-consider further investigation.” Dr Loxton has provided a report in which he advises:  That Mrs McManus had expressed to him that she “did not want investigations performed” and that she at no stage had malaena stools, loss of weight or a change in bowel habits.

 That in view of the above Dr Loxton did not investigate Mrs McManus’ condition further. However, he says that in retrospect he could have done so.

 That he “feels dreadful about the situation” and expresses his “deepest and heartfelt sympathy to (Mrs McManus’) two daughters.” The investigation has also included a review of Mrs McManus’ care and management at the RHH undertaken by Research Nurse, Mrs Libby Newman, along with the provision of a report by Dr Bell. In the latter document Dr Bell has focussed upon the care provided to Mrs McManus by both the John Street Medical Centre, particularly by Dr Loxton, and by the RHH following Mrs McManus’ presentation to the ED and before the diagnosis of her cancer.

Upon these matters Dr Bell has advised:  Once the diagnosis of anaemia due to iron deficiency is established, attempts must be made to identify the cause. Several of the common causes such as colonic and uterine cancer have ominous prognoses unless discovered and treated promptly.

 Contrary to standard medical practice Dr Loxton made no attempt to find a cause for Mrs McManus’ iron deficiency.

 The standard of care provided by Dr Loxton to Mrs McManus was inadequate.

 The shortcomings in the care provided by Dr Loxton led to the late diagnosis of Mrs McManus’ colonic cancer. By the time the diagnosis was made Mrs McManus’ general condition had significantly deteriorated so that she was less able to tolerate the rigours of surgery.

 At the RHH the assumption made by Dr Vial that Mrs McManus’ iron deficiency was attributable to malabsorption was erroneous. In Mrs McManus’ case her distal small bowel had been resected. Iron absorption only occurs in the proximal small bowel.

 It was clear that Mrs McManus was suffering from severe anaemia with iron deficiency yet no attempt to find its cause was made whilst she was in the medical ward. This represented sub-standard medical care.

 Dr Vial has explained her decision not to investigate the cause of the anaemia on the basis that Mrs McManus’ poor functional status made aggressive pursuit of a diagnosis contrary to her interests. If this was Dr Vial’s rationale then she was, in the very least, required to discuss her favoured course of treatment with the patient and her family before a final course was settled upon.

 Even if Mrs McManus’ cancer had been promptly diagnosed by the RHH medical staff and the surgery undertaken at the first opportunity there was a possibility that the same tragic outcome would have evolved.

Findings, Comments and Recommendations: I accept Dr Bell’s opinion that anaemia due to iron deficiency is a condition that mandates immediate investigation. Here the evidence shows that from late 2010 Dr Loxton recognised that Mrs McManus was anaemic. Thereafter he regularly treated her condition with vitamin B12. However, he did not initiate any steps to establish a cause for the anaemia. This situation persisted for approximately 20 months in the face of clear signs that Mrs McManus’ general state of health was steadily declining. Even an attempt made by Dr Ward to have Mrs McManus’ iron deficiency investigated at the RHH was not followed up by Dr Loxton. In Dr Bell’s view Dr Loxton’s failure to investigate the anaemia constituted an “inadequate” standard of care. In my view this is a generous assessment. Rather, I consider the level of care provided by Dr Loxton fell grossly short of that standard which Mrs McManus was entitled to expect of her general medical practitioner.

As subsequent events established, Mrs McManus was suffering cancer of the colon and it was this condition that was causative of her anaemia. Had the cancer been diagnosed shortly after the anaemia presented; and appropriate investigation would have made such diagnosis an easy task; remedial surgery could have been undertaken. On the assumption that at this time Mrs McManus was in a reasonably robust state of health Dr Bell advises me that Mrs McManus had an 80% prospect of surviving the surgery for one year and a 50% prospect of survival for 5 years. Regrettably, by the time the surgery did take place Mrs McManus’ general conditioning had so declined that she was unable to survive it beyond two days.

I have decided not to hold a public inquest into this death because my investigation has sufficiently disclosed the deceased’s identity, the time, place, relevant circumstances concerning how her death occurred, and the particulars needed to register the death under the Births, Deaths & Marriages Registration Act 1999. I do not consider that the holding of a public inquest is likely to elicit any important additional information further to that disclosed by the investigation conducted by me. The circumstances of Mrs McManus’ death do not require me to make any further comment or any recommendation.

I conclude this matter by conveying my sincere condolences to Mrs McManus’ family and loved ones.

Dated: 27 November 2015 at Hobart in the State of Tasmania.

EXPLANATORY NOTATION On 30 October 2014 Coroner, Olivia McTaggart, as Delegate of the Chief Magistrate for the State of Tasmania, directed that the investigation by Coroner Rod Chandler into the death of Mrs McManus be re-opened and the findings be re-examined on the ground that new facts or evidence had come to light affecting the original findings. The findings made by this document follow that re-opened investigation and replace those previous findings made on 7 April 2014.

Rod Chandler Coroner