When ‘Conservative Treatment’ isn’t enough: recognising and responding to clinical deterioration

Date: December 14, 2016


Inquest into the death of Mark Anthony Plumb

Key Points


Mark Plumb passed away on 23 October of 2014 as a result of multiple organ failure and sepsis with peritonitis and pancreatitis, among other complications, stemming from an elective procedure to remove a gall stone.

A 76 year old man in relatively good health, with his only known medical condition being lupus, Mr Plumb underwent gall stone removal at the Friendly Society Private Hospital in Bundaberg on 19 September 2014. Post-operatively and overnight, his condition deteriorated quickly and he became septic. By 5:30 the following morning, Mr Plumb was experiencing acute renal failure and peritonitis, and a decision was made for the deceased to be transferred to the Wesley Hospital in Brisbane for urgent management by way of the Royal Flying Doctor Service.

At Wesley Hospital, Mr Plumb underwent emergency surgery, during which it was found that the bile and pancreatic duct were partially disconnected from the duodenal wall and were leaking into the abdomen. Post-surgery, Mr Plumb remained unwell and his prognosis worsened, with a decision subsequently being made for palliative care measures.

This case was referred to Queensland’s coroner’s court after a review of the deceased’s medical records and an expert review that raised concerns, including “significant deficiencies” in Mr Plumb’s post-operative care.  The issues before the coroner included an assessment of the:


It was found reasonable in all of the circumstances for Dr Anderson to perform the gallstone removal surgery on Mr Plumb. There was no evidence to suggest that Mr Plumb was not aware generally of the risks involved with anaesthetic and the procedure.

The coroner’s conclusions emphasised the importance of “systems being in place to recognise and manage a deteriorating patient”. There was no escalation of treatment in post-operative care despite Mr Plumb’s deterioration being noted for over 11 hours, during which time he became septic.

The coroner considered Mr Plumb’s post-operative care to be adequate until Dr Anderson received results of a CT scan and failed to physically review Mr Plumb or take a less conservative approach to his care. While the CT scan did rule out pancreatitis as the cause of the pain, at this time a perforation became highly suspected. The failure to physically examine Mr Plumb represented a missed opportunity to consider alternative management plans, which could have involved earlier specialist intervention.

The Root Cause Analysis (RCA) undertaken by the hospital and the five causal statements identified in relation to the death of Mr Plumb was largely accepted by the coroner. However, the coroner did make a recommendation that wherever possible, a RCA should involve relevant members of the treating team and also provide feedback as to the outcome of the analysis. This practice should be employed across the board, especially in public hospitals.

Importantly, the coroner found that an earlier recognition of deterioration and transfer for appropriate care would likely have improved Mr Plumb’s chances of survival from the perforation. However, the coroner did not express concerns in respect to the time it took Mr Plumb to be transferred by air bearing in mind the available resources.

Lessons Learnt

Mr Plumb’s death highlights the importance of having proper communication systems in place between staff to quickly and accurately identify deteriorating patients, so a more involved course of post-operative care can be undertaken. It also provides a warning about taking a conservative care approach without adequately examining test results (in this case, a CT Scan) and physically examining the patient.

The coroner’s comments on the RCA undertaken by the hospital also provides a suggestion as to best practice when analyses of this kind are conducted.


The Health Law team

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