During coronial inquests doctors can face
criticism which may lead to disciplinary, civil or criminal proceedings. Avant’s
now-regular event, the Moot Court, this year gave attendees a vivid insight into
how an everyday situation can unfold and threaten a doctor’s reputation and
career if expert advice is not sought early.
This year’s spirited
inquest into the death of Jane Joe was held on June 18 2015 at Sydney’s Westmead
Hospital with 400 attendees and a cast that included Avant and external experts.
Proceedings were overseen by barrister Cameron Jackson (as the NSW Coroner) and
moderated by John Kamaras, Special Counsel – Coronial, Avant Law.
On 11 July 2011, 76-year-old Ms Joe injured her leg after slipping
at home, She presented to Westmead Hospital’s emergency department where an
x-ray revealed she had a longitudinal fracture of her left tibia.
Joe was treated by RMO Dr Michael Swannie (Michael Swan, Senior Solicitor, Avant
Law). In accordance with the advice of the orthopaedic registrar on-call, Dr
Swannie applied a non-weight-bearing splint and advised ice and elevation. He
discharged her on analgesia and instructed her to see an orthopaedic surgeon in
A week later, Ms Joe died suddenly from a pulmonary embolism
due to a deep vein thrombosis (DVT).
Criticism of Dr Swannie’s history
taking and treatment
Counsel Assisting the Coroner (barrister Stephen
Barnes) told the court that Dr Swannie did not seek assistance from his medical
indemnity organisation when police asked him in November 2012 for a statement
regarding Ms Joe’s death.
Dr Swannie’s statement, which outlined
that he had taken Ms Joe’s medical history, reviewed her medical records and
examined her, was inconsistent with his contemporaneous notes.
Swannie proved to be a rather unreliable witness after he confirmed that he had
recorded that Ms Joe suffered from fibromyalgia, but omitted to record that she
suffered from a number of conditions including systemic lupus erythematous
(SLE), based on her medical records. He said it was a ‘complete shock’ when he
discovered Ms Joe had suffered from SLE for 15 years.
coroner also raised concerns about a note that Dr Swannie submitted as evidence,
which he wrote a day after Ms Joe died to refresh his memory of the case. The
coroner criticised Dr Swannie for not informing the police of the note when they
had asked him for a statement for the coroner.
treatment of Ms Joe also attracted scrutiny from the expert witness, Dr Peter,
an eminent vascular surgeon. Dr Peter advised that Ms Joe should have been given
low-molecular weight heparin due to her high risk of developing a DVT based on
her age, obesity, immobility due to the fracture and the fact that she suffered
SLE which can lead to a higher risk of spontaneous thrombosis.
Recommendation to change policy for prevention of DVT
In view of
Dr Peter’s expert opinion, Mr Barnes highlighted the NSW Health policy directive
‘Prevention of Venous Thromboembolism’ which recommended that all in-patients in
NSW public hospitals at risk of developing a DVT be considered for treatment
Unfortunately, Westmead Hospital’s protocols did
not require prophylaxis to be given to patients such as Ms Joe who were treated
in the emergency department. This was borne out by Dr Swannie’s statement which
said: “DVT prophylaxis was not considered for Mrs Joe, full stop. She was
already taking aspirin.”
Although Dr Peter’s credibility as an
expert witness was also questioned during the inquest, he agreed with Mr Barnes’
recommendation that the NSW Health policy should be amended to enable all
patients in out-patient settings in emergency departments to be considered for
Ultimately, Dr Swannie accepted that Ms Joe was
at risk of developing a DVT and should have received prophylaxis.
Swannie’s treatment appropriate?
Edson Pike represented Dr Swannie at
the inquest and, while he conceded that his medical notes were inadequate, he
said he should not be criticised for failing to elucidate Ms Joe’s history of
“…It’s a pretty long stretch to suggest that failure to get
that information should somehow be sheeted home to the doctor. He asked the
questions - he didn’t get the responses,” Mr Pike said.
also argued that the profession was divided on the issue of whether appropriate
management mandated the administration of DVT prophylaxis and any criticism of
Dr Swannie in relation to this issue was inappropriate.
While the coroner said he had misgivings about all of the
witnesses’ evidence during the inquest, there was “no evidence to suggest that
any practitioner did anything other than the best with the information that they
had the time.”
“My recommendation is to the Minister for NSW Health
that consideration be given to the creation of a guideline or policy that
addresses patients with a lower leg fracture treated in the emergency department
of a hospital to be assessed, and if appropriately, be treated for the risk of
venous thromboembolism (VTE),” the coroner said.
Outcomes and lessons
In fact, following similar real cases, the policy was amended in
2014. The amended policy now requires that:
adult patients admitted to NSW public hospitals be assessed for the risk of
- any adult patient who has
significantly reduced mobility must be assessed for VTE before being discharged
from the Emergency Department; and
- patients identified at risk of VTE should receive
Seeing the case unfold
in this case helps bring to life a number of key lessons:
- Members should notify Avant early in the coronial
process so that their interests can be protected.
you keep good records.
information on the process and issues involved in coronial investigations and
Read our Risk IQ factsheet: The
coroner and you and Medical
records: the essentials
View our new Risk IQ video: Preparing
a statement for the coroner.
Visit our webpage: Understanding
the legal process: Coronial inquiries.
Avant would like to thank our
guest stars for the night:
Coroner – Cameron Jackson, Barrister, Second Floor Selborne
- Counsel Assisting the
Coroner – Stephen Barnes, Barrister, 16 Wardell Chambers
- Counsel for Dr Swannie – Edson Pike, Barrister, Level 2
- Moderator –
John Kamaras, Special Counsel-Coronial, Avant Law
Dr Michael Swannie – Michael Swan, Senior Solicitor, Avant
- Expert witness, Dr Peter –
Associate Professer Peter Thursby, General Surgery -
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