Grandfather's death not reported to coroner despite hospital blunders

In late June, 2024, a crisis unfolded in the short-staffed emergency ward at Caboolture hospital just north of Brisbane.

Flatlining one morning in one of the bays was 86-year-old grandfather Leo Barraclough.

Clinicians swarmed trying to revive the pensioner using a drug best known for reversing overdoses in heroin addicts.

The scene was in almost unimaginable contrast to how he had arrived at the state-run hospital.

The afternoon prior, the local resident had walked into emergency seeking treatment for his ongoing severe back pain.

Now 14 hours later, doctors were trying to get a tube down Mr Barraclough's vomit choked throat to help him breath while they tried to find his heartbeat.

Later that day his family received news of his death.

The hospital told them the cause of death was Neutropenia — a condition involving weakened immunity and pneumonia.

And in official documents staff ticked boxes.

One confirmed the case did not need to be reported to the coroner who is supposed to be informed if a patient death is caused by bad health care.

The other described the death as "not unexpected".

The family were horrified.

The death was anything but "not unexpected" for them.

"There were so many things that didn't add up," Mr Barraclough's daughter Kym Vassiliou said.

They were right to be suspicious.

An ABC investigation found there had been multiple problems with the care provided to Mr Barraclough before he fell into an unconscious state from which he never woke.

From his patient records, a confidential internal health service review and from interviews with clinicians, the ABC tracked what appeared to be numerous examples of flawed care before his decline.

But because the hospital had been able to decide the death was "not unexpected" and not reportable to the coroner, an independent investigation, or reforms to improve care were less likely.

The case raises questions about how health services decide when a death needs to be reported to the coroner who could investigate and recommend changes to prevent other deaths.

"My father was known to be an advocate who had helped many people in his community," Ms Vassiliou said.

"He would hate that this hospital would get away with what they did and that more people might come into the same situation."

Condition not expected to cause death

The coroner's office's official advice said a death is reportable if the health care caused or contributed to the death or a failure to provide health care caused or contributed to the death.

"And the death was an unexpected outcome of the health care being provided," it said.

Its advice also said: "Before the health care was provided, an independent person qualified in health care, would not have expected the care to cause or contribute to the death."

When Mr Barraclough, an asthmatic, arrived at the hospital, he already had a serious ailment called Myelodysplastic Syndromes (MDS), a slow acting blood cancer where bone marrow fails to produce enough healthy blood cells.

The condition was not expected to cause his sudden death, according to his family.

But it did make him susceptible to infection.

Within 45 minutes of Mr Barraclough being triaged as a non-urgent patient, he was given Ibruprofen and some Endone for his back pain, according to patient notes.

The confidential review undertaken by the Metro North Health Service that oversees Caboolture's hospitals revealed there was an issue with this.

It found Mr Barraclough's vital signs had not been recorded despite the fact Ibuprofen "should be used with caution in patients with asthma".

It was the start of regular failures to properly record Mr Barraclough's condition so that his decline would be recognised and appropriate treatment provided.

Mr Barraclough was then left to wait three hours without having his observations taken.

The review flagged this delay but then revealed there was no "minimum standard" of how often observations should be taken in this circumstance.

More delays and missed opportunities

At 6:30pm, after Mr Barraclough's wife complained that he was having breathing problems, a nurse took his observations showing his oxygen levels had fallen.

He was given six puffs of asthma medication but received no physical examination, his charts confirm.

Any concerns about his condition were not escalated, which was a "missed opportunity", according to the review.

At 6:50pm a student nurse tried to put Mr Barraclough on a program involving extensive tests and possibly antibiotics — key treatment for a patient in his condition.

But this program, called a Sepsis Pathway, was never signed off by a senior nurse, the review revealed.

He did not receive antibiotics until many hours later.

Finally, five hours after his arrival he received a rapid assessment from a doctor.

This was "a considerable delay", the review acknowledged.

Tests were ordered, but in a bungle the results which contained critical information were not passed on to the doctor.

The results showed Mr Barraclough was pancytopenic, meaning he was more susceptible to infection due to his abnormal blood cell levels.

Bizarrely, at the same time Mr Barraclough's charts stated that his condition had improved.

This too was an error.

The results were "incorrectly scored and incomplete" with Mr Barraclough's oxygen saturations not documented, according to the review.

At 9:20pm he received more opioid medication for his pain, 5mg of Endone.

The review flagged this as another "missed opportunity" because no sedation score was recorded.

The score was important as it could have indicated whether the medication was working or causing side effects.

Mr Barraclough was moved to a spot called "overflow" outside of the emergency department — possibly due to "space constraints", the review noted.

At 11:23pm his observations showed another decline.

His oxygen levels were now around the 80 per cent mark, according to notes. Healthy levels are above 95 per cent.

But these observations were incomplete, failing to record a deterioration score used to determine treatment, his patient charts confirm.

At midnight Mr Barraclough complained and tried to leave, his wife Vonnie Barraclough said.

This led to him being seen by a doctor who referred him to a registrar, but this took nearly another hour.

The registrar prescribed a dose of antibiotics but this took nearly another hour before they were actually administered.

This meant Mr Barraclough had waited nearly 12 hours to receive this crucial treatment, a delay highlighted by the review.

"A missed opportunity for goal directed therapy (sepsis management)," it said.

Wife leaves thinking all is fine

Ms Barraclough left thinking everything would be fine, but it would be the last time she would speak to her husband of 61 years.

At 1:54am Mr Barraclough's oxygen levels were recorded as dropping to 79 per cent and he was put on oxygen.

The amount of oxygen he received is difficult to confirm as his charts and the review contradicted each other — one chart note said one litre while the review said it was two litres.

Shortly after Mr Barraclough received another dose of opioids for pain but no sedation score was done, the review revealed.

A Queensland Health clinician who reviewed Mr Barraclough's charts and did not want to be identified due to restrictions on public servants commenting queried this.

"Opioids are known to slow breathing. A patient in his condition would need to have been very closely monitored in this situation," the clinician said.

At 3:50am Mr Barraclough's charts stated that a clinician scored his pain at an eight out of 10.

And at 3:55am he was given more opioid pain medication in the form of a 5mg drip of morphine.

Minutes later he lost consciousness.

His critical state was then only "incidentally" noticed by someone "passing by the room", according to retrospective notes made by a hospital doctor.

Precisely how long this took is not clear from the retrospective notes.

His oxygen levels were found to be critically low at about 60 per cent, according to the notes.

He was repositioned and put on 15 litres of oxygen, but his levels remained at 60 per cent.

By 4:25am he was "un-responsive" and an official emergency call was triggered.

Five minutes later he was found to have no central pulse. Adrenalin was administered and defibrillator pads were attached.

A dose of Naloxone — a powerful drug that reverses opioid overdoses — was administered at 4:32am but his heart still was not beating.

Seven minutes later doctors put a tube down his throat to get oxygen into his lungs, according to the notes.

Large amounts of vomit were found, the notes stated.

It is unclear from the notes and the review exactly how long the vomit might have been blocking his airway.

Finally, at 4:41am, a heartbeat was found but due to the amount of time he spent with low oxygen levels, he was unable to sustain blood pressure and breathing and was pronounced dead at 10:36am with the cause listed as Neutropenia and Pneumonia.

Family left in the dark

His family were initially completely unaware of the many problems with his care.

The hospital's decision not to report the death to the coroner indicated its the care did not cause or contribute to his death or fail to prevent it.

But his patient notes and even the Metro North review raised questions about what role the problematic care played in his death.

One clinical summary note made by a doctor who saw Mr Barraclough about 4:45am speculated about the cause of his cardiac arrest.

The note left a question mark next to the following medical scenarios: sepsis and lower left lung lobe pneumonia, aspiration, opiate toxicity and pulmonary embolism.

The review also raised questions.

Under the heading of contributing factors it listed opioid administration without use of sedation scoring, a delay in administering antibiotics and the Naloxone.

Multiple moves through emergency and nursing notes absent, delayed or incomplete were also referenced.

The review revealed the Australian Medication Handbook recommended a patient in Mr Barraclough's condition receive 0.5mg of Morphine.

The hospital gave him 5mg.

But the review team "did not reach consensus to any reduced prescribing for this patient however noted it may have been prudent to administer the lower prescribed dose of the IV opioid and titrate to pain score/sedation score".

It suggested the Endone opioid painkiller given to him at about 2am could have peaked around the same time he received the morphine drip.

But it did not say this caused his death.

The review team also discussed whether there was a delay to recognise the vomit in Mr Barraclough's airways during the aspiration process.

But again, the review drew no conclusion claiming it was difficult to determine from the documentation.

The review made three recommendations that included escalating patients when emergency was crowded, flexible staffing and better communication of critical results.

Only the flexible medical staff recommendation was accepted.

The review said Mr Barraclough's decline was likely due to him having underlying carbon dioxide retention and acute respiratory failure due to his pneumonia and compromised immunity.

The ABC provided the notes and the review to nurse and patient advocate Amanda Duncan, who recently exposed issues with the way deaths were being reported in Tasmania.

She said Mr Barraclough's case deserved further investigation.

"Knowing or suspecting what caused a patient's death does not automatically mean the death does not warrant being reported to the coroner for potential investigation," she said.

Death eventually referred to the coroner

Mr Barraclough's family remain angry about how he was treated and how his case was not reported to the coroner.

"What we wanted was some action to be taken to stop this from happening again, for transparency to be brought into the process," his son Mark Barraclough said.

Last month ABC sent dozens of questions to Metro North querying why each incident of problematic care did not result in the death being reported to the coroner.

Four days later, Metro North said that his death had been referred to the coroner "out of an abundance of caution".

A spokesperson said the service offered its sincere condolences to the family.

"Clinical decision in the emergency department are based on patients' symptoms and known medical history, and all unexpected deaths are reviewed," the spokesperson said.

"The initial review identified improvements around documentation which have been implemented, and Caboolture hospital held open disclosure meeting with the family."

Due to the case being referred to the coroner no further comment could be made, the spokesperson said.