‘Couldn’t believe it’:Top doctor’s shock after hospital destroyed records following Adam’s death

The former head of a major Sydney intensive care unit was shocked to discover medical records were destroyed after a 20-year-old patient was left brain-dead when staff failed to fix a dislodged breathing tube,an inquest was told.

Adam Fitzpatrick had survived a horror car crash in the NSW Riverina in August 2020,but a series of catastrophic errors in the intensive care unitat St George Hospital later led to his death.

Associate Professor Theresa Jacques was the head of the intensive care unit at St George Hospital until her retirement last year.

Associate Professor Theresa Jacques was the head of the intensive care unit at St George Hospital until her retirement last year.James Brickwood

His family told the 10-day inquest,which began on Monday,that they had requested crucial medical records within days of Fitzpatrick’s death,only for them to be withheld,and then later destroyed.

In 2021,a joint investigation byThe Sydney Morning Herald andA Current Affair revealed that when Fitzpatrick’s 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 Adam’s life.

The support was turned off after he was declared brain-dead having been starved of oxygen for 43 minutes while in cardiac arrest.

At the opening of the inquest,a lawyer for the South Eastern Sydney Local Health District apologised to Fitzpatrick’s family and friends.

Adam Fitzpatrick,who died five days before his 21st birthday.

Adam Fitzpatrick,who died five days before his 21st birthday.Supplied

“As the inquest unfolds,it will become clear this was an emergency situation where unfortunately mistakes were made,” said Anne Horvath SC,adding that hospital executives were in attendance to listen and improve patient care.

Adam’s mother,Philippa Fitzpatrick,told the court she was initially incorrectly told her son’s death was unavoidable because his breathing tube became blocked.

Crucial medical records of Fitzpatrick’s death were withheld from the family before being destroyed,she said.

“We all know accidents happen,sometimes things go wrong,” Philippa Fitzpatrick told the hearing,before Deputy State Coroner Derek Lee.

“It would have been far easier for us as a family to accept what had happened and to be able to grieve … had we been told the truth right from the start.

“We would have been saved 2½ years of trying to find out what happened.”

The former head of the intensive care unit at St George Hospital,Associate Professor Theresa Jacques,shook her head when the destruction of the records came up during cross-examination.

“I’m just aghast at the experience of the family on medical records,” she said.

“I couldn’t believe it … I wasn’t aware of that.”

Philippa and Peter Fitzpatrick leave Lidcombe Coroner’s Court on Monday with their daughters Amanda (left) and Emma.

Philippa and Peter Fitzpatrick leave Lidcombe Coroner’s Court on Monday with their daughters Amanda (left) and Emma.James Brickwood

The counsel assisting the coroner,Patrick Rooney,said among the issues examined at the inquest would be when and how Fitzpatrick’s breathing tube became dislodged and at what point staff should have suspected this had happened.

It would consider whether resuscitation efforts were adequate and whether it was necessary for an ear,nose and throat specialist to be called to the hospital to replace the tube.

The inquest would also examine the communication between the hospital and the Fitzpatrick family at a series of meetings in the days following the incident.

The meetings were tense as Adam Fitzpatrick’s mother,a veterinarian,and sisters Amanda and Emma,a paramedic and lawyer respectively,used their expertise to challenge inconsistencies in the hospital’s version of events.

Rooney noted that the family were grappling with “profound loss,continuing anguish and heartbreak” after losing Adam five days before his 21st birthday.

Building a life in the NSW Riverina region,Fitzpatrick had big dreams for the future,“with a job that he loved,living in a town that he loved,with the girl that he loved”.

“All efforts will be made over the course of the next 10 days to piece together what happened,” Rooney said.

During the hearing,Philippa recalled that Fitzpatrick was sometimes being left unattended in the ICU even though he was meant to be having one-to-one care.

She recalled he would wake up from sedation agitated and thrashing and on one occasion his breathing tube – inserted through a hole in the neck known as a tracheostomy – pulled free from the ventilator.

No one came even though the machine was alarming,and she had to reconnect the tube herself,Philippa said.

In the hours before Fitzpatrick went into cardiac arrest,Philippa recalled raising concerns with a doctor about the potential for the breathing tube to become dislodged as he was weaned off his sedation.

“It was protruding at a strange angle I thought,” Fitzpatrick recalled of the breathing tube. “Not sitting flat against his skin.”

Jacques worked at the ICU at St George Hospital from 1989 until her retirement in November last year. She was head of the unit at the time of Fitzpatrick’s death,but was not rostered on to the area on the day of the emergency.

Jacques was asked whether there were times when a patient who was meant to be receiving one-to-one care wasn’t monitored by a nurse.

“Clearly on the evidence that I heard there appears to be that there were occasions when there was no nurse in the room,” she said.

Jacques conceded that,at the time she ran the unit,staff shortages meant the doctors on duty were not always at the level of seniority management wanted to achieve.

“This is in COVID and staffing was a huge challenge,” she said.

The inquest continues.

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Carrie Fellner is an investigative reporter for The Sydney Morning Herald.

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