Tuesday, April 17, 2012

Woman's treatment while on liver transplant list was tragic, inquest told

20 to 30 percent of patients on the wait list for an organ transplant die before a donor is found for their second chance at life. However, in this case it would seem that the patient's death was the result of human errors at the hospital.

The Sydney Morning Herald, Australia
A Sydney mother was discharged from hospital after falling victim to a "comedy of errors" that ended in her death from multi-organ failure, an inquest has been told.

Marie Haywood, 43, was admitted to Campbelltown Hospital on December 21 when she had fluid drained from her abdomen due to a chronic liver condition.

Mrs Haywood, who had been on the liver transplant list since August of that year, was also diagnosed with pneumonia and given increasing levels of morphine and other pain medication, a coronial inquest heard on Monday.

By Christmas Day she told nurses that she was "always in pain", counsel assisting the coroner Kristina Stern told Glebe Coroner's Court.

On Boxing Day, when she was discharged, Mrs Haywood reportedly complained of chest pain and having a red, pussy wound where a cannular had been inserted.

She had also vomited and was having trouble walking.

On the same day, blood test results showed a clear deterioration in her renal function.

"It appears that no one actually checked those results ... and they were not taken into account," Ms Stern said in her opening address.

"The only doctor that had physical contact with her was an intern who had no experience of her case."

She was discharged despite test results showing that her "overall condition had clearly deteriorated during her admission", Ms Stern added.

Mrs Haywood wasn't given a discharge summary or plan, and the doctor who signed off on her discharge did not physically review her.

Her condition worsened and she returned to hospital with her husband 16 hours later.

When she died on December 29 her primary cause of death was listed as multi-organ failure.

In a report read to the inquest, Professor David Morris described Mrs Haywood's time in hospital from December 21 to 26 as a "comedy of errors" that ended in her "spiralling into multi-organ failure".

He said the lack of co-ordination and communication between medical staff was "tragic", and the managing of her urine was "seriously inadequate".

Speaking outside the inquest, her husband John Haywood said he hoped the coronial investigation would result in improvements to the way hospitals are run.

"I would like to come out at the end and see that people can't be discharged without being seen," he told reporters.

"I always believed that when you went to hospital, you went there and you would be okay, but it doesn't always happen that way."

The inquest before NSW Deputy State Coroner Hugh Dillon continues.

© 2012 AAP

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