A man who died from a ruptured spleen the day after a colonoscopy could have been saved if an on-call nurse had given him the correct medical advice.
Alan Edward Stewart, 70, underwent the routine medical procedure at the Royal Melbourne Hospital in 2018, after returning an abnormal bowel cancer screening test.
He was discharged from the hospital a few hours after the 20-minute procedure, as is standard practice.
About 10.44pm the next evening, Stewart began suffering abdominal pain, dizziness and shortness of breath.
His wife Sherrilyn called the hospital and was transferred to the Nurse-on-Call service.
She detailed her husband’s symptoms and Stewart even spoke to the nurse, saying he felt giddy, hot and short of breath before he had to give the phone back to his wife.
The nurse advised Stewart to maintain hydration, take Panadol for the abdominal pain and see a doctor within the next 12 hours.
Stewart took some Panadol and went to bed about 11pm but when his wife checked on him at 3.15am, she found him unresponsive.
He was declared dead at the scene, with an autopsy confirming the cause of death was a ruptured spleen.
Coroner Paul Lawrie found the nurse’s incorrect advice stopped Stewart from going to hospital in time to receive emergency care.
“(The emergency) assessment and care may, subject to his clinical presentation on arrival at hospital, have prevented his death,” Lawrie stated in his report.
He did not make any recommendations to Medibank Health Solutions Telehealth, which provides the Nurse-on-Call service, noting an internal review had already been done and appropriate changes made.
The coroner, however, made two recommendations to the Royal Melbourne Hospital after finding inadequate communication with the couple on what to do if Stewart began experiencing serious symptoms.
He recommended the hospital review its written patient discharge information to remove ambiguity and include signs of significant internal haemorrhage on the serious symptoms list.
It should also review its discharge procedures to ensure a record is kept of all the information provided to the patient, the coroner said.