Facts
On 24 January 2020, Queensland State Coroner James McDougall handed down his findings following an inquest into the death of Maria Willersdorf, an 87 year old woman who died after a seemingly straightforward steroid injection procedure.
The deceased had a longstanding history of chronic back pain as a result of spinal osteoarthritis and in late March 2015, presented to her General Practitioner due to escalating back pain.
On 9 April 2015, the deceased’s General Practitioner completed a referral for the deceased to undergo targeted steroid injections to the facet joints affected by osteoarthritis in the thoracic and lumbar spine.
On 14 April 2015, the deceased attended IRIS Imaging for the planned procedure which was performed by Dr Emechete, Radiologist and owner of IRIS Imaging. However, soon after the procedure (the exact nature of which was considered at length at the inquest), the deceased complained that she felt a bit faint and was taken to one of the treatment rooms.
Dr Emechete then applied a cannula and “put the flush in” at which point he gave evidence that the deceased ‘came around’ and started talking and Dr Emechete requested that an ambulance (QAS) be called.
Dr Emechete then left the deceased alone in the treatment room and subsequently (the timing of which was unclear), her blood pressure dropped to 60/40mmHg and she became unresponsive. QAS’ evidence was that when they arrived, no life saving measures were being performed on the deceased and when QAS asked if anyone knew CPR, no one answered.
QAS observed that the deceased was in cardiac arrest and performed resuscitation until spontaneous circulation was achieved 20 minutes later. However, the deceased ultimately died in hospital five days later.
Findings
The Coroner found that the cause of death was hypoxic-ischaemic encephalopathy against a background of (previously undiagnosed) valvular heart disease and (treated) spinal osteoarthritis.
Expert evidence was given as to the nature of the procedure performed by Dr Emechete and after much consideration, it was found that Dr Emechete deviated from the requested procedure and performed a single thoracic epidural nerve block at T12 (rather than facet joint steroid injections).
As to the cause of the cardiac arrest, the Coroner found that the epidural injection was a contributory not primary factor in the deceased’s death as her hypotension lead to the cardiac arrest although the hypotension was likely caused by the epidural injection.
In this respect, one of the experts explained that thoracic epidural can spread in a cephalic distribution causing blockage of the sympathetic nerves to the heart which can then result in both slowing of the heart rate and arterial vasodilation (causing hypotension).
In terms of Dr Emechete’s deviation from the requested procedure, the Coroner found that the epidural injection was not the most appropriate procedure in terms of safety and pain relief however, considered that it was “not inappropriate” treatment in the context of Dr Emechete’s clinical assessment of the deceased’s pathophysiology.
In regards to Dr Emechete’s technique in performing the procedure, the Coroner found that the epidural injection was correctly inserted into the epidural space and was carried out successfully.
However, the Coroner determined that the more pertinent issue was Dr Emechete’s failure to adequately assess and respond to the deceased’s medical emergency and in this respect found that Dr Emechete failed to administer sufficient intravenous fluids / vasoactive drugs and failed administer resuscitation by the use of a defibrillator.
The Coroner found that this substandard care jeopardised the deceased’s survivability and ultimately contributed to her death in the context of her undiagnosed underlying valvular heart disease.
It was also found that IRIS Imaging was inadequately equipped to respond to the deceased’s medical emergency and in this respect, Dr Emechete breached the Royal Australian New Zealand College of Radiologist (RANZCR) standards for, inter alia, failing to (a) have available minimum resuscitation equipment to perform Advanced Life Support including a defibrillator and resuscitation drugs and (b) ensure that attending personal were trained in resuscitation.
The Coroner also found that (a) Dr Emechete ought to have obtained the deceased’s past medical history (which would have revealed her pre-existing hypotension), (b) the ‘nerve block’ consent form did not adequately identify the procedure nor did Dr Emechete identify the specific risks associated with the epidural injection and (c) the deceased was not provided with enough time to consider the alternate procedure nor the consent form.
Recommendations
In considering the above issues, the Coroner made two recommendations that within 12 months from the date of the findings, RANZCR amend:
- The Standards of Practice to require electrocardiography monitoring for physiological monitoring of patients while undergoing spinal tap, epidural and spinal nerve root block, where there risk of harm to a patient, due to risk factors (including but not limited to age, frailty, poor health and co-morbidities), is greater and or likely to be more serious or result in injury (Tier A Interventional Procedures); and
- The Radiodiagnosis Curriculum to require radiologists performing contrast and sedation, to hold CPR certification to provide advanced life support.
The Coroner also made specific recommendations to IRIS Imaging including that the practice undertake thorough assessments of patients including the identification of comorbidities and associated risk, refer patients to the emergency department if the patient has manageable pain, not perform Type A interventional procedures (such as epidural) unless, inter alia, Dr Emechete completed an Advanced Life Support and CPR Workshop and annual refreshers, an ECG machine be purchased and used in the recovery room, a nurse be present at all times during procedures and recovery; all patients undergoing intervention procedures remain for 60 minutes in recovery while wearing a pulse oximeter and attached to an ECG and the nurse to conduct regular checks and undertake stock audits of the resuscitation drugs.
This article was written by Katharine Philp, Partner and Dee Kelly, Senior Associate.
