“Alarms were going off,but nobody came for quite some time and I had to reconnect the ventilator tubes myself,” Ms Fitzpatrick said.
“I kept thinking,why isn’t someone coming? If I had not been present on this day Adam could have died.”
The root cause analysis later 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.
‘It was almost like we were questioning God’
After the surgery,the Fitzpatricks were relieved to see their son “looking like Adam again”.
Adam was returned to intensive care,with plans to allow the sedation to wear off gradually. His tracheostomy appeared “secure and intact”.
However,the next morning Philippa felt uneasy because the tube appeared to be protruding at a strange angle.
She raised this with a nurse,who waved off her concerns. Ms Fitzpatrick had to vacate the room while a physiotherapist attended and alerted a nurse and a doctor as she was leaving.
The doctor was reassuring,Ms Fitzpatrick recalled.
“She said,worst-case scenario,if the tube comes out we’re all trained in replacing the tubes.”
While the family was at lunch,a nurse noticed Adam was struggling with mucus build-up and strong fits of coughing,according to the analysis.
After Adam started making gurgling noises his ventilator’s alarm activated,with doctors and nurses rushing in.
Despite the malfunctioning tracheostomy,Adam was breathing spontaneously on his own and levels of oxygen in his blood were normal.
However,doctors administered a drug that paralysed Adam’s muscles so a bronchoscope – a camera allowing doctors to see inside the airways – could be passed down the tracheostomy tube to check for blockages.
The analysis found that if the drug had not been administered,there was a possibility Adam could have maintained adequate oxygen levels on his own.
After the bronchoscopy,Adam’s condition deteriorated and he went into cardiac arrest.
CPR was commenced and doctors tried a variety of methods to restore his airways,but none were successful.
It was only when the ear nose and throat (ENT) medical officer arrived that it was found the tracheostomy tube was dislodged and in the pretracheal space.
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.
The family returned from lunch to find a huddle of doctors around Adam in the ICU.
“We stood there for an uncomfortable amount of time with no one saying one single word to us,” Amanda recalled.
The family allege they were told the tracheostomy tube had become blocked,Adam had been without oxygen and his condition was “not good”.
It was left to Philippa and Amanda,with their medical backgrounds,to tell other family that Adam was likely to die.
During meetings that followed,the family allege facts kept changing to explain inconsistencies and staff were “aggressive and threatening” when challenged.
“It was almost like we were questioning God,” Amanda recalled.
The family say they battled for months to get medical records,only to find they were inaccurate and incomplete.
Two key documents requested on the day of Adam’s death were not given to the family,who were later told they no longer existed because they were on machines that only stored data for three months. The hospital insisted the documents were not destroyed but “overridden”.
The family were blindsided to finally learn the true sequence of events when they received an apology and a copy of the root cause analysis in February.
After receiving the news,Philippa was hospitalised with takotsubo cardiomyopathy,also known as broken heart syndrome,where the heart muscle is weakened by an intense surge of stress hormones.
An investigation found that the ENT officer was away from the hospital and was originally told it was not necessary for him or another doctor to return because the situation was under control.
One of two senior doctors rostered on to the ICU was also absent due to a “personal issue”.
The root cause analysis found there was a lack of clarity as to who was the team leader,equipment was used incorrectly which may have collapsed Adam’s lungs,safety equipment that should have been used was not and Adam’s tracheostomy emergency management plan was inadequate.
It also found “inconsistent evidence” when it examined how recently staff had been trained and assessed in the handling of tracheostomy emergencies.
The original version of the analysis approved by St George Hospital did not identify any root causes of Adam’s death or make any recommendations.
It was changed after it was sent to executives within the South Eastern Sydney Local Health District for review.
‘Incredibly confronting and stressful’
Over the past decade,pioneering work has taken place within the international medical community to curb the number of adverse events involving tracheostomy patients.
TheGlobal Tracheostomy Collaborative was formed in 2012,spearheaded by doctors from the United States,UK and Australia’s Austin Hospital in Melbourne.
They developed a five-prong approach to preventing adverse events,that includes co-ordinated team care,standardisation of care protocols,multidisciplinary education and staff allocation,patient and family involvement,and use of data tracking to drive improvement.
More than 50 hospitals from around the world have joined,reducing the severity of major adverse events involving tracheostomies by 54 per cent and improving overall quality of care through safer,swifter recovery.
Associate Professor Michael Brenner,from the University of Michigan School of Medicine,is the collaborative’s president.
He tells theHerald tragic incidents involving tracheostomies are all too familiar for doctors in his field but system-wide improvements can radically reduce their incidence.
Professor Brenner says the accidental dislodgement of a tracheostomy tube is one of the most common adverse events and doctors or other health professionals trying to replace a dislodged tube could often end up pushing it into the soft tissues in the front of the neck instead of successfully placing it into the windpipe.
“Sometimes the catalyst for hospitals to improve tracheostomy care is that something terribly unfortunate has happened,” he says. “We’d really like to get to a place where hospitals preemptively take steps to improve,such as joining the collaborative,before an event happens.”
He drew on the “swiss cheese” model of risk,where a number of holes in the cheese have to line up for a catastrophic event to occur. A multi-prong approach could plug at least some of those holes,Professor Brenner says.
“This story of a family member,knowing that something’s not right and trying to sound the alarm and being unheard,that’s very pervasive in medicine internationally. So if we can just amplify the voice of the patient,that seemingly small act can transform healthcare.”
Dr Stephen Warrillow,director of intensive care at the Austin Hospital,says many of the principles that can reduce adverse events are not overly complicated,but notes individual doctors may not see a patient with a tracheostomy more than a couple of times a year.
“If you’re called urgently to a crisis and it’s many years since you’ve dealt with a patient with a tracheostomy,you’re trying to troubleshoot a difficult problem in a situation where you only have minutes to spare,” he says.
Dr Warrillow says his first concern is always for patients and their families when adverse events occur but notes preventing such incidents also has a profound effect on the healthcare workers involved.
“You come to work to do a good job and look after people,so it’s incredibly confronting and stressful for healthcare workers watching a patient dying and feeling perhaps nothing you’re doing is working.”
‘I feared the next call-out’
St George Hospital’s intensive care unit was barred from training junior doctors in 2019 amid allegations of bullying and dysfunction among senior staff.
The Fitzpatricks have queried whether a bullying culture in the ICU created an atmosphere where junior staff did not feel comfortable asking for help.
Amanda Fitzpatrick says she was a “shadow of my former self” returning to work as a paramedic after watching her parents kiss their son goodbye and bury him.
“I feared the next call-out,” she wrote in a letter to the hospital. “I feared blood and trauma.
“Most of all I feared making a mistake that would end someone’s life,just as your team had done to Adam.”
Emma Fitzpatrick,a lawyer,has moved into the medical negligence sector since her brother’s death to help other families find justice.
“We’re 15 months down the track and it feels like nothing has been done and we haven’t gotten anywhere despite hours and hours and hours of heartache,anguish and effort,” she says.
Hospital managers admit they have not been able to “adequately answer” the family’s questions arising from the root cause analysis,partly because some clinicians involved no longer work at the hospital.
They promised an external investigation,which was called off last month so as not to interfere with investigations by the State Coroner.
The family is also pursuing legal action,but can only sue for their own nervous shock because,unlike other jurisdictions,the NSW legal system does not recognise “wrongful death”.
“It’s not about the money as such,but that his life is valued so little,” Philippa Fitzpatrick says.
The root cause analysis document is also not admissible in court,on the basis this encourages clinicians to be more frank and truthful in their accounts.
Ms Fitzpatrick now struggles with feelings she failed Adam by not doing more to escalate her concerns about the tracheostomy on the day of his death.
“Adam’s death was completely preventable,” she says.
“We have lost our most precious son,and more importantly he has lost his whole future,and this has happened in completely unacceptable circumstances. We want to ensure that this does not happen to other families.”
She says it is frightening to think other preventable deaths may be swept under the rug where families lack medical knowledge to challenge what they are told.
“We want people to know these cover-ups do happen.”
A St George Hospital spokeswoman acknowledges Adam Fitzpatrick did not receive the care he deserved in August 2020 and the hospital extended a sincere apology to his family.
She says the hospital is fully co-operating with an independent investigation by the NSW Coroner.
“St George Hospital is committed to processes that result in learning from incidents and to improving the care we provide to our patients,” the spokeswoman says.
WATCH:See the Fitzpatrick family’s story onA Current Affair on Monday at 7pm on Channel Nine.
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