Coroner finds Tasmanian Health Service showed indifference to stroke victim’s care

SERIOUS ISSUES: Coroner Rod Chandler found serious shortcomings in the THS treatment of a Burnie man who died in hospital in 2012. Picture: File photo
SERIOUS ISSUES: Coroner Rod Chandler found serious shortcomings in the THS treatment of a Burnie man who died in hospital in 2012. Picture: File photo

A coronial investigation into the death of a 41-year-old Burnie plumber in 2012, found ‘elements of serious farce’ in his medical treatment.

Coroner Rod Chandler said the events leading to Darryl Morris’ death “demonstrated an indifference to Mr Morris’ proper care and elements of serious farce.”

In his January 2018 report, Mr Chandler found that, “(i)f Mr Morris had been promptly diagnosed and transferred to the stroke unit on 7 September 2012 that there was a real likelihood that he could have been successfully treated and made a functional recovery. Unfortunately he was denied that prospect.”

Mr Morris was a 41-year-old plumber living in Burnie with his family. On September 4 2012, he started to feel ill and two days later, he collapsed at home and was admitted to the North West Regional Hospital.

A doctor diagnosed encephalitis or possibly a stroke, and ordered an MRI (image) of his brain, but put on the form that he was an outpatient.

Mr Morris was admitted to hospital and the next day was again diagnosed with encephalitis.

He continued to have symptoms of a stroke, but did not have a brain MRI until Monday September 10, four days after his admission

Although the MRI results were put online immediately, nobody alerted his medical staff. By noon the next day Mr Morris was taken to the Royal Hobart Hospital. He died there the following day.

Mr Chandler said two farcical features of Mr Morris treatment required highlighting. 

“The first is the decision by staff at the Launceston General Hospital to permit Mr Morris to be returned to the NWRH without first discussing the MRI findings with his clinicians.

“The second farcical element concerns the PACS (the system which made the MRI available). The evidence shows that although this system was in place by May 2012 the medical and nursing staff involved in Mr Morris’ care were either unaware of its existence or did not know how to access it.”

Mr Chandler said staff caring for Mr Morris did not see the results of his brain image for 21 hours after it had been available. 

He recommended five changes to the Tasmanian Health Service, of which three have been adopted. The THS had not informed him about the other two, one of which was for MRI results to be relayed immediately.

A THS spokesman said, “(t)he Tasmanian Health Service takes every opportunity to review and improve patient care.”

“As the Coroner’s report itself identifies, the THS has already acknowledged the recommendations and acted on them.”