Patient 'died prematurely1

Press, 6 December 1985, Page 13

Patient 'died prematurely 1

PA Tauranga A terminal cancer patient died prematurely when a drain inserted into his chest pierced a vein in his liver, the Coroner’s Court in Tauranga was told. The Coroner, Mr Michael Cooney, found that Leonard Hubert King, of Tauranga, died * following medical misadventure.

Mr Cooney asked a junior house surgeon at Tauranga Hospital, Jillian Maree Caisley, if she had taken an X-ray of Mr King’s chest before inserting the drain. Dr Caisley said that she had inspected an X-ray, but had not realised the extent of the change in the location of Mr King’s organs since an earlier drain was done. The medical superintendent of the hospital, Murray Loughlin, said he had discussed with Mr King his condition and it was decided not to proceed with surgery.

Mr King was unlikely to have lived more than several weeks, he said.

Dr Caisley said that she became involved with Mr King’s case when he had a chest infection. Mr King had become distressed by shortness of breath and a drain was put in his right pulmonary cavity. The drain gave initial relief but it failed and was removed on September 13. By September 18 he was distressed again by shortness of breath and a further X-ray revealed a large collection of fluid, Dr Caisley said.

She said she decided to insert another drain, at the same level of the previous one but more posterior. About 20 minutes after the drain went in, Mr King was sat up by nurses so his bedding could be changed. The drain bottle filled with about two litres of dark blood within a few minutes. “I realised then that a

serious complication had arisen but its nature was not evident to me,” Dr Caisley said.

Mr King was severely shocked and collapsed, but after a few minutes a feeble pulse returned and there was a slight improvement in his condition, she said. She summoned a surgical registrar and an anaesthetist Mr King was resuscitated with fluids and oxygen.

Portable X-ray equipment revealed that the drain had almost certainly entered the liver. ■

Mr King died after about two hours, she said. A pathologist at the hospital, lan Douglas Beer, said the drain had been removed by nursing staff before the body went to the mortuary, but he found a 0.8 to 1centimetre wide perforation in the liver and that a large vein in the liver had been lacerated. The Coroner told Alan King, a son of the deceased, that in view of a possibility of a claim to the Accident Compensation Commission he would make files avail- - able.