After complications from open gallbladder surgery at Echuca Regional Health where a blood vessel was damaged, 71-year-old Rochester man Gary William Bruce died at Bendigo Hospital on June 3, 2023.
Mr Bruce had surgery at ERH on May 20, 2023, because he had gallstones and an inflamed gallbladder.
During the surgery, despite the main liver artery remaining intact, a smaller artery was accidentally damaged.
The surgeon stitched the artery, stopped the bleeding and checked blood flow was restored.
Mr Bruce was admitted to the ERH High Dependency Unit overnight where he suffered at least two episodes of low blood pressure.
Despite the first episode starting at about 11pm, the Medical Emergency Team wasn’t called until about 1am on May 21.
Mr Bruce had emergency surgery at about noon after an urgent CT scan at 6.40am revealed major internal bleeding that started at the site of the gallbladder surgery had spread.
He was taken to Bendigo Hospital Intensive Care Unit where he experienced ongoing kidney failure and continued to deteriorate. He died two weeks later.
Despite being given the option of waiting for an available bed at Bendigo Hospital, Mr Bruce had the surgery closer to home so his family could easily visit him.
Releasing her findings into Mr Bruce’s death, Coroner Catherine Fitzgerald found the complication during the gallbladder removal surgery was “appropriately recognised” and “treated accordingly”.
However, she said there were “deficiencies” in the response to Mr Bruce’s deteriorating condition overnight at a critical time for him.
She said the lack of MET calls was a “significant issue” and a “missed opportunity” to prevent his death.
“He was critically unwell,” she said.
“If a MET call had been activated earlier, it is quite possible that Mr Bruce may have been returned to theatre sooner and may have experienced a different outcome.”
In a statement to the court, ERH director of nursing and midwifery Maree Woodhouse conceded there were 10 times overnight where there should’ve been a MET call — including a period when he hadn’t urinated for eight hours — despite only one being made.
The coroner recommended ERH undertake improved education, training and awareness of the hospital’s deteriorating patient response with medical and nursing staff, and gather evidence to demonstrate improvement among staff.
She also recommended ERH consider implementing a mechanism so anaesthetic or other critical care-trained specialists such as ICU or Emergency Department staff are available to provide advice to a junior doctor who attends overnight MET calls.
In a statement to the court, ERH chief medical officer Dr Annemarie Newth reported a number of changes had been made since Mr Bruce’s death.
These included the appointment of co-clinical directors of medicine, mandatory attendance of senior medical staff for a second MET call, and bringing in Bendigo Health special intensivists.
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