Legacy of change after 'undignified' death in hospital
THE family of a man who died in hospital after a string of system failures say they are happy their father's legacy will live on.
Bundaberg man James Patrick Talbot was visiting family in Brisbane for Christmas in 2013 when he became unwell.
The 87-year-old was taken to Brisbane's Wesley Hospital where he died two days later.
In findings that were delivered on Friday following an inquest, Deputy State Coroner John Lock found that hospital miscommunication and system failures led to Mr Talbot's swollen abdomen being left untreated.
Mr Lock's findings said Mr Talbot's death triggered the hospital into implementing changes; a positive move that Mr Talbot's daughter Debbie Croxford and his son Shane Talbot said came out of a very bad situation.
"We're hopeful that dad's legacy will mean other people will be treated better," Ms Croxford said.
A Wesley Hospital spokeswoman said the hospital accepted the Coroner's findings and said the hospital had already made a number of changes to improve communications between staff and with family.
Mr Talbot's death certificate said he died from aspiration pneumonia but on Friday Mr Lock found the man died on December 31 from a strangulated bowel.
The day after Mr Talbot was admitted into hospital, a nurse noted that Mr Talbot's abdomen was "very distended"- swollen.
But when the doctor later examined him, this was not noted.
In his findings, Mr Lock said the doctor's practice, similar to other specialists, was not to read the nursing progress notes but rely on oral updates from nursing staff.
He also said Ms Croxford had later tried to raise concerns with another nurse that her father was vomiting and had a swollen stomach. That nurse did not inspect Mr Talbot's stomach, Mr Lock said.
Mr Lock said if bowel obstruction had been identified it probably would have led to Mr Talbot being given palliative care because surgery was a high risk and not viable.
But he said the critical issue was that Mr Talbot and his family did not get the opportunity to make such decisions.
"Mr Talbot could have been made more comfortable and his family could have been with him," Mr Lock said.
"Instead he died alone and in an undignified manner."
Mr Lock said that since Mr Talbot's death, the hospital had implemented a "Let us know" process for escalation of family and patient concerns.
A Wesley Hospital spokeswoman said the hospital had made changes to improve communication including an escalation protocol to ensure a rapid response, extra training and improved handover procedures.
"We wish the family to know that the enhancements and improvements are directly related to our ongoing consideration of Mr Talbot's death," the spokeswoman said.
It's been an emotional rollercoaster for Mr Talbot's family since his death but Ms Croxford and Mr Shane Talbot said it had been worth the fight it because of the improvements that had occurred.
- ARM NEWSDESK