*The contents in this blog relates to legislation in New South Wales.

The Sydney Morning Herald reported recently on the tragic story of Adam Fitzpatrick, a young man from the NSW Riverina region, who was pulled from the wreckage of a car crash in August 2020. He was transferred to St George Hospital for significant reconstructive surgery on his jaw and face. He was told he would lose an eye, but that he would fully recover.

Adam was admitted to ICU at St George Hospital and had a tracheostomy tube inserted through his neck which connected to a ventilator that pumped oxygen into his lungs. At some stage during his admission, the tube became dislodged. Adam began struggling with mucus build-up, strong fits of coughing, and start making gurgling noises after which the ventilator’s alarm was activated and doctors and nurses rushed in.

The Sydney Morning Herald and A Current Affair reported that when the breathing tube became dislodged, doctors failed to recognise the problem, were unable to fix it and decided against calling for the help of a specialist who could have replaced the tube in minutes and saved the man’s life. During the period in which the staff were unsure what to do, Adam was starved of oxygen for 40 minutes.

It was only when an ear nose and throat (ENT) medical officer arrived that it was found the tracheostomy tube was dislodged. The officer immediately placed the tube back into the correct position. But scans three days later confirmed Adam had suffered catastrophic brain injuries from oxygen deprivation and he was declared dead.

An internal investigation, known as a root cause analysis, was undertaken by the hospital which found Adam’s death was caused by a delay in recognising the tracheostomy tube was dislodged and replacing it. The report says, “There was an ineffective emergency response due to deficiencies in co-ordination, equipment, training and leadership which led to patient death.”

The root cause analysis also found Adam was meant to have one-on-one nursing care, but it wasn’t provided because his nurse was attending a training session. No formal handover took place notifying the other nurse on duty she would temporarily have to supervise Adam. The near-miss wasn’t logged until after Adam’s death, the report found.

For more information about the types of internal investigations public hospitals perform, see our previous blog here.

Adam’s mum said that his death was “completely preventable.”

Adam’s case highlights the need for clear communication between healthcare providers, clear policies and guidelines surrounding treatment and use of equipment and the need for continuous education of healthcare providers.

Get in touch

At Turner Freeman, our experience tells us that Adam’s story is one of many stories of healthcare treatment gone wrong. Not all poor medical treatment amounts to negligence and it is important you get the right advice.

If you are concerned about your treatment, get in touch with us on 13 43 63. We have specialist medical negligence lawyers throughout NSW who will assess your case and provide personalised advice regarding your legal entitlements. Our medical negligence lawyers are located across NSW including in our offices in ParramattaSydneyWollongongNewcastle and Toronto.