1037
PAPUA NEW GUINEA
[IN THE CORONERS COURT OF JUSTICE]
 01 of 2009
IN THE MATTER OF LAVINIA FIMIAMBA (DECEASED)

WEWAK: D.SUSAME

2009: 25th February, 25th March,20th May,17th
June, 17th, 22nd, 29th July, 26th August,
9th, 26th September, 7th, 28th November, 9th ,16th,
23rd December,

CIVIL- 

Cases Cited
Nil

References

Counsel
Nil

15th January, 2010

DECISION

INTRODUCTION

D. Susame:-This is an inquiry into the death of a young 16 year old lass, Lavinia Fimaimba originally of Harigen village Kubalia but residing at Tangara settlement, Wewak. At the time of her death the deceased was in her tenth grade at the Mercy Secondary School, Yarapos, Wewak.

2. The deceased passed away at 9.07am on 7th January 2009 at the Wewak General Hospital while receiving medical treatment.

3. The death was reported to the Coroner on 7th January 2009. Because the family members alleged the death was associated to professional negligence by the hospital staff, an initial decision was then made by the Coroner to hold a formal inquiry to ascertain the factual circumstances of the death. The inquiry was assisted by Chief Sergeant Sela from the police prosecution’s unit, Wewak, and also the Damien Manga the Clerk responsible for coronial matters at the Wewak Hill District Court Registry.

4. The inquiry commenced its hearing on 25th February 2009 and concluded on 23rd December 2009. The decision was reserved till 15th January 2010 which I now publish.

EVIDENCE

5. Evidence received consists of written statements from a total of nine witnesses. Most of the witnesses were made to attend to testify at the inquiry including Doctor Moses Manwau, a Private Medical Practitioner in town and who actually performed the autopsy. Other documentary evidence includes the patient’s clinical and treatment records and medical certificate of death. Samples of blood and certain parts of body organs were taken and sent to Port Moresby and to Australia for scientific analysis or toxicology and histology. But the reports were not available at the inquiry. 

FINDINGS

6. Prior to her death the deceased had on 2nd January 2009 complained of a painful and irritating throat. So early in the morning of 3rd January 2009 her parents took her to Wewak General Hospital for treatment. 

7. The nursing sister on call that morning saw the deceased at about 7.45am. The sister got her complaints and examined her. She diagnosed her with Upper Respiratory Tract infection, Ear infection and Malaria. Based on her diagnosis she administered the relevant treatment. The sister then placed the patient in the day ward while she sent a note for the doctor on call that day to see the patient.

8. The doctor on call that day was not available. The patient had to wait the whole morning still under medication until a Health Extension Officer (HEO) stood in and did further examination of the patient at about 11.30am or 12.30 past noon.

9. The HEO diagnosed her with Malaria and Otitis Media and prescribed the treatment to be administered. Thereafter the patient was admitted to the medical ward for further review by a Medical Doctor.

10. The patient was conveyed to the ward at about 2.00pm and allocated a bed. At the ward a nurse did observation of the patient. No drugs were administered while waiting for the doctor to come and see the patient. 

11. No doctor attended to the patient until about 4.00pm the patient collapsed and went into fit. The sister and the nurses on duty attempted to resuscitate the patient when the doctor arrived and took charge of the proceedings and had the patient placed on life support system.

12. The patient was in a state of coma and was on life support system till Sunday 4th January 2009 when the family members were advised by the doctor that despite the patient being on life support system clinically she was brain dead except for the heart that was beating.

13. The family members insisted the patient remained under the life support system to see if the patient will revive. Finally, on 7th January 2009 the patient’s heart ceased beating and the respirator was removed after the family members were notified by the doctor.

POST MORTEM FINDINGS

14. Post mortem was conducted on 08th January 2009 by Doctor Moses Manwau a private medical practitioner in Wewak. At the time of the post-mortem medical records of the patient were not made available to Doctor Moses but were later produced at the inquiry. 

15. At the inquiry Doctor Moses expressed concern that whenever a death occurs in the hospital medical records of the patient must be made available to him as the Doctor conducting the post mortem. In situations like this such reports are not available to him for a much detail report to be furnished to the Coroner. 

16. The doctor’s comments are noted. In the absence of any legal arguments I can only say this. There is no legal obligation for the hospital to release the patients’ medical reports to the Doctor conducting post mortem except by an order of the Court or Coroner at an inquiry or court proceedings.

17. According to doctor Manwau, the patient died as a result of an Acute Trachitas complicated by Aspiration Pneumonia due to acuteness of the symptoms. The doctor was of the opinion that the patient died of a treatable condition if treatment were given promptly death would have not occurred. 
 
18. The medical certificate of death issued from the hospital states the patient died from Anaphylactic Reaction, Septicaemia, Aspiration Pneumonia and Cerebral Hypoxia. Stating that in lay man’s language the patient died of widespread infection of the blood from bacteria and virus which caused poisoning and affected the vital organs of the body.

ALLEGATIONS OF NEGLIGENCE

19. Allegation of professional negligence was raised by the family members. They argued had the doctors attended to the patient promptly and properly diagnosed the cause of illness and treated her accordingly death would not have occurred. 

20. I want to say the following. From the evidence I accept that when first seen by the Nursing Sister at the Outpatient Clinic in the morning the patient was in a sick but stable condition. For time being necessary treatment was administered according to the Sister’s diagnosis of the patient’s illness while a note was sent for a doctor to come and conduct further review of the patient’s condition. 

 21. Although it was not a case of extra emergency situation, the patient was obviously in a distress condition. The Sister and the Nurse had done what was necessarily as required of them. It was a case they could not adequately handle. The Sister rightly so then made the decision for the referral of the patient to a Medical Doctor and not a Health Extension Officer. It was therefore a case for a Medical Doctor to handle. A Doctor should have attended and reviewed the patient and recommend appropriate medical action and treatment at the earliest possible opportunity to stabilise the patient’s deteriorating condition. 

22. The patient’s condition was getting worse. For the patient to wait for a Medical Doctor from about 9 o’clock in the morning to 4 o’clock in the afternoon when she collapsed and went into fit resulting in subsequent death, in my mind is unacceptable.

23. I endorse the views expressed by the Doctor who conducted the post mortem that the patient died of a treatable condition. If only there was earlier detection of the patient’s problems by a Medical Doctor, the death would have been prevented.

MEDICAL TREATMENT ADMINISTERED

24. The patient was treated with certain drugs and IV fluids while waiting for a doctor to see her and when she was in comma and undergoing resuscitation process.

25. According to medical opinion heard the deceased may have possibly died also of Acthus Reaction (i.e. a reaction of the body from the drugs received). 

26. However, in the absence of any histology and toxicology reports this inquiry is not able to make a conclusive finding on this issue.

SUMMARY OF FINDINGS

27. The deceased is Lavinia Fimaimba, young 16 year old lass from Harigen village, Kubalia, but residing at Tangara settlement with her parents.

28. The deceased was taken to Wewak General Hospital for treatment on 03rd January 2009 and while at the hospital died at 9.07am on 07th January 2009.

29. The cause of death is as disclosed in the medical certificate of death. (See paragraph 18 above)

30. This inquiry is not able to conclude the death was attributed to professional negligence of the hospital staff. The inquiry can only say this. There was in fact some delay and lack of prompt action by the Medical Doctor to see and review the patient when referral was made. 

RECOMMENDATIONS

31. This inquiry has heard that the practice used at the Hospital to get a Medical Doctor to attend to referral patients is by way of note sending through a security guard or any available support staff. In this particular case several notes were sent for a Doctor to attend to the patient but with no favourable response. 

32. Perhaps one contributing factor that caused the delay is attributed to the problem of locating the doctor to effect service of the notes that were sent.

33. My view is that this problem will continue to prevail to the detriment of patients unless a much effective and efficient communication network system is adopted and used not only at the Wewak General Hospital but in major hospitals in the country. A modern paging system for all the doctors and major hospitals in the country is recommended by this inquiry.