NICHOLAS Wells, a young father seriously injured in a car crash in 2016, died when staff at John Hunter Hospital failed to identify the seriousness of a treatable but life-threatening internal injury and incorrectly attributed his worsening symptoms to a withdrawal from drugs.
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Deputy State Coroner Magistrate Elizabeth Ryan on Monday delivered her findings and recommendations after a coronial inquest into the death of Mr Wells outlined the many shortcomings and deficiencies in the 24-year-old's care at John Hunter Hospital in May, 2016.
Mr Wells was driving from Sydney to Brunswick Heads after visiting his young daughter, Sapphire, when he fell asleep and crashed at Bulahdelah early on the morning of May 22, 2016.
He suffered a fracture to his neck and leg and a perforated bowel, an injury that would go untreated and ultimately claim his life.
Mr Wells' step-father, Luis Feliu, said the 24-year-old's honesty with paramedics about consuming methamphetamine earlier that morning created a stigma that followed him throughout his treatment at John Hunter Hospital.
"Because he was deemed a drug user right from the start their judgement was clouded," Mr Feliu said.
"There was a cascading of errors born from that stigma."
Mr Feliu and Mr Wells' mother, Sue Nakkan, say that admission of drug use coloured the staff's opinion of their son and meant they didn't prioritise his care and his health deteriorated.
"The neglect and lack of duty of care was catastrophic," Mr Feliu said.
And, importantly, the coroner found that clinical staff too readily interpreted Mr Wells' increasing agitation as the symptoms of drug withdrawal rather than the signs of developing peritonitis and sepsis secondary to his untreated bowel injury.
In her findings, Magistrate Ryan delivered a blistering assessment of Mr Wells' level of care, ruling that he died when the bowel perforation he suffered in the crash "did not receive adequate care and treatment from medical and nursing staff" at John Hunter Hospital.
There was no one single decision or mistake that led to Mr Wells' death; it was a combination of errors, miscommunications, lack of training and experience and inefficient policy.
Ms Ryan, highlighting the opinions of two medical experts who gave evidence during the inquest, was particularly scathing of the care provided to Mr Wells by international medical graduate and unaccredited surgical registrar, Dr Taryn Kusyk.
Dr Kusyk reviewed Mr Wells on the day he presented at John Hunter Hospital and recorded a possible diagnosis of a small bowel injury.
The suspicion of a bowel injury was well founded, Ms Ryan said.
But the management plan implemented was the subject of expert criticism due to a failure to direct further surgical assessment, investigation and treatment of what was a suspected life-threatening condition.
"Expert opinion was unanimous that the management plan which Dr Kusyk documented was wholly inadequate and demonstrated poor clinical judgement, in that it failed to reflect the seriousness of the suspected injury," Ms Ryan said in her published findings.
Ms Ryan said a "key systemic failure" which contributed to Mr Wells' death was the appointment of Dr Kusyk to the surgical registrar role in 2015, an acknowledgement made by the hospital's director of medical services, Professor Michael Hensley.
The John Hunter Hospital executive were transparent and upfront with Mr Wells' family about his death and the failings in his level of care, Mr Feliu said.
They apologised during the inquest and again on Monday after the findings and recommendations were published and say they have made a number of changes to improve patient safety and care.
"I offer my sincere condolences to Mr Wells' family and again apologise that we did not provide him with the standard of care he deserved," Karen Kelly, Executive Director of the Greater Metropolitan Health Service, said in a statement.
"Following Mr Wells' death in 2016, the District commissioned an investigation straight away, the findings and recommendations of which we shared with Mr Wells' family. From this investigation, we made a number of changes to improve patient safety and care, including bolstering staff training and local procedures, installing new equipment and undertaking regular audits. The Coroner has welcomed the improvements already made by John Hunter Hospital as evidence of our commitment to increasing the safety of our patients. We have received the findings of the NSW Coroner and accept her recommendations. We will now focus on how we can best implement these recommendations, in addition to the improvements we have already made, to ensure that an incident like this does not occur again."