Palliative Care Patient Deaths

Coroner re-sends Tocumwal hospital deaths to DPP
By court reporter Jamelle Wells

The New South Wales coroner has made a number of recommendations after hearing more evidence about the deaths of two patients in Tocumwal Hospital on the New South Wales-Victorian border.

The inquest into the deaths of palliative care patients Ralf Grenfell in 2005 and Bob Cooling in 2007 was adjourned in March last year when Coroner Mary Jerram referred the matter to the Director of Public Prosecutions.

The DPP decided at the time to take no action.

The inquest heard that before they died, Dr Balaji Rao gave both men the muscle relaxant Atracurium, which stops a patient from breathing.

The drug is normally only used as an anaesthetic in conjunction with breathing machines.

The coroner also heard that since 2007, the Greater Southern Area Health Service has changed its drug administration and security and increased its palliative care training.

After the inquest resumed in Sydney on Tuesday to consider additional evidence from hospital staff, the coroner again referred the matter to the DPP.

Ms Jerram also recommended the Department of Health:

Issue a health safety notice warning all medical practitioners and nursing personnel of the potential negative effects of neuro-muscular blocking agents and that those agents should not be used without appropriate ventilator support.

That the department take steps to promote services and advice available from clinical nurse consultants and clinical nurse specialists in palliative care and pain relief. Those steps should include the monitoring, on an annual basis, of the use of those services throughout the state in non-metropolitan hospitals which rely on general practitioners for the provision of medical services.

That the department undertake a review, in conjunction with the NSW Nurses Association and other industry participant groups, of the support processes for whistleblower staff.

That the department reviews its education and training programs for health professionals and support staff with a view to ensuring there is a significant emphasis and focus on:

their role as advocates for clients of the health system;
the role of each person when a complaint has been made.

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