Coroner's Finding: de-identified KW

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased and family by the direction of the Coroner pursuant to s 57(1)(c) of the Coroners Act 1995) I, Olivia McTaggart, Coroner, having investigated the death of KW Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is KW, date of birth 24 November 1936.

b) KW was 87 years of age, married and lived in New Norfolk. She suffered several medical conditions including diabetes, peripheral vascular disease and atrial fibrillation. She had also suffered past hip and pelvic fractures. On 21 August 2023, KW presented to the Emergency Department of the Royal Hobart Hospital (RHH) after suffering several recent falls at home. She was assessed as having a periprosthetic fracture of the right distal femur and underwent distal femur replacement surgery on 30 August 2023. Her recovery was poor, and she required extended inpatient therapy.

On 18 October 2023, she was transferred to the New Norfolk District Hospital (NNDH) for ongoing rehabilitation and recovery from surgery.

Unfortunately, she did not progress with rehabilitation and her general condition continued to deteriorate. She was therefore transferred back to the Royal Hobart Hospital on 16 November 2023. Five days after her admission to the RHH, nasogastric tube feeds had been established.

KW continued to deteriorate, and, on 21 December 2023, she developed a large painful haematoma in her right thigh, seemingly spontaneously, close to the site of the previous fracture and the surgery.

It is not known what caused the haematoma but, in her malnourished

state, it may have been caused by only a small degree of pressure. I am satisfied that it was associated with the fracture.

As a result of this haematoma, she lost blood and became anaemic and delirious. The option of orthopaedic surgery was deemed to present unacceptably high risks, and KW did not wish to undergo surgery. After further discussions between her medical team and family, she was treated palliatively with comfort medications. She passed away in hospital on 25 December 2023.

c) KW’s cause of death was right thigh haematoma as a consequence of a periprosthetic fracture of the right distal femur caused by several falls at home. Her significant cardiac conditions and diabetes contributed to her death.

d) KW died on 25 December 2023 at Hobart, Tasmania.

In making the above findings, I have had regard to the evidence gained in the investigation into KW’s death. The evidence includes:

• The Police Report of Death for the Coroner;

• Tasmanian Health Service Death Report to Coroner;

• Affidavits verifying identification;

• Opinion of the forensic pathologist regarding cause of death;

• Tasmania Health Service records;

• Review of hospital care by the Coronial Nurse Specialist; and

• Advice from Dr Anthony Bell, Coronial Medical Consultant.

Comments and Recommendations One significant issue that has arisen in this investigation relates to KW’s functional decline in her long hospital admission and whether her deterioration and death could have been reasonably prevented.

For this reason, I sought an independent review of KW’s hospital care by the Coronial Nurse, Mr Kevin Egan. Mr Egan provided a detailed and helpful report,

providing the opinion that KWs functional decline related to her significant underlying medical comorbidities, prolonged trauma in the leg, malnutrition, failure to progress with rehabilitation, and her age.

Specifically, Mr Egan identified that a significant part of her decline whilst a rehabilitation patient at the NNDH was associated with her poor ability to swallow, poor nutritional intake and significant weight loss. Mr Egan noted that a Safety Management Event1 was completed by the dietician on 16 November 2023 with concerns that KW’s nutritional intake was lacking and that she was suffering from “hospital acquired malnutrition.” Mr Egan criticised the management of KW, stating that there was no definitive or early plan put in place to address her lack of nutritional intake, weight loss and malnutrition prior to transfer from the RHH or while she was at NNDH.

Mr Egan stated in his report: “While I acknowledge the patient’s choice in some of these decisions was to blame, it appears from the records, that the significance of the malnutrition and weight loss over a 4–5-week period and the inability to thrive after the operation and during rehabilitation was lost or clouded. From admission to NNDH, there is documented nausea, food refusal, difficulty swallowing (due to Zenker’s diverticulum2) and changes to diet consistency (normal diet, soft, minced and moist etc). Dietician reviews, meal changes, swallow assessments, supplementary food options etc, all failed to address the malnutrition. She was at risk of refeeding syndrome upon re-admission to RHH in mid-November and had lost 7.1kg in one month with a low BMI of 20 kg/m2 while at NNDH.

The Zenker’s diverticulum was first diagnosed in 2021 and confirmed on investigation and imaging in 2022. The deceased was reluctant to have a surgical correction. There is evidence in the RHH records, prior to rehabilitation and NNDH admission of poor appetite and some swallowing difficulties. The malnutrition is a contributing factor for the general functional decline and ultimately the death. Malnutrition can cause muscle wasting, 1 Severity Assessment Code 3 – moderate harm.

2 Oesophageal dysmotility.

reduced strength, confusion, organ failure, loss of skin integrity, non-healing wounds, altered coagulation, altered electrolytes and fluids and has impacted on the deceased’s ability to overcome the trauma of the fracture and the surgery. Although PEG feeds had been established (and nasogastric feeding prior to this) the effect of the delay on the ability to heal, skin integrity, energy and strength was clear.

The deceased never regained pre-hospital level of function once admitted.

She was never deemed suitable to be discharged home, and discharge planning had commenced for her placement in respite or permanent admission to an aged care facility. She was regularly assessed as ‘well below functional baseline’ during the extended hospital admissions. She was not able to stand and had permanent contracture of the right leg which was not able to be surgically corrected, and the patient disengaged with physiotherapy and rehabilitation services.” Mr Egan also recognised in his report that KW’s ongoing refusal of care, assistance and rehabilitation attempts at both hospitals were significant factors in her decline.

I find that KW’s malnutrition did not directly cause her death but was a contributory factor.

I forwarded a copy of Mr Egan’s report to the Executive Director of Medical Services Hospitals South, Dr John Gallichio, for his comment. Dr Gallichio reported that that KW’s weight was charted weekly on the weight chart, and he set out the efforts made by clinicians and staff at NNDH to manage her nutrition. He stated that enteral nutrition support via percutaneous endoscopic gastronomy (PEG) was considered during her admission. However, he stated that the treating hospital staff considered that initiation of nasogastric enteral nutrition support was not possible due to inadequate training, expertise, and limitations with equipment. Dr Gallichio also stated that hospital management at the time held the same view. Dr Gallichio also emphasised that KW’s oesophageal dysmotility, ongoing nausea, refusal of treatment, urinary tract infection with delirium, and difficulty swallowing contributed to an inability to sustain nutrition in the long-term.

Dr Gallichio indicated that various processes and discussions had been commenced regarding reviewing nutrition management at NNDH.

Concluding comments Following her falls and her surgery distal femur replacement surgery on 30 August 2023, KW did poorly. Although she was eventually admitted to NNDH in midNovember 2023 for rehabilitation, it does not appear that her rehabilitation could ever have been realistically achieved. She was of advanced age with multiple comorbidities, including cardiac conditions. The nature of her fracture and the consequent surgery meant that her prognosis was likely poor.

Prior to her transfer to NNDH, she had not made progress, remained with swallowing issues, and was refusing meals and assistance. Despite her family requesting the transfer, it was overly hopeful to expect that she would improve or that NNDH as a district hospital had the clinical skills to achieve her rehabilitation in such difficult circumstances. It is concerning that KW lost a significant amount of weight whilst ostensibly under rehabilitation. If she wished to be actively treated, she should have been transferred back to the RHH at an earlier time for an enteral feeding regime to be implemented. Alternatively, given her very poor prognosis, discussion between clinicians and family should have occurred regarding changing her goals of care from rehabilitation to palliation. I comment that if KW’s progressive malnutrition could have been halted at an earlier time, it is unlikely that she would have been able to resume normal intake without enteral nutrition support.

I recommend that the Tasmanian Health Service review the adequacy of existing policies and guidelines regarding the care and treatment of rehabilitation patients at the New Norfolk District Hospital, specifically pertaining to ongoing assessment of the suitability of patients for rehabilitation, the scope of the treatment measures available to rehabilitation patients, and the circumstances under which rehabilitation patients should be transferred to the RHH for further or different treatment.

I recommend that, following such review, the Tasmanian Health Service implement necessary changes to the existing policies and guidelines, together with a strategy for staff education.

I convey my sincere condolences to the family and loved ones of KW.

Dated: 21 January 2026 at Hobart, in the State of Tasmania.

Olivia McTaggart Coroner