The Corruption and Crime Commission (CCC) tabled a report in Parliament on 14 March 2023 following its preliminary investigation into an allegation of serious misconduct at Rockingham General Hospital.
The allegation specifically related to the death certification process for Mr Kevin Reid who died at RGH in September 2022, after being admitted to hospital on 23 August 2022 with shortness of breath and fluid overload. He had a history of cardiomyopathy and chronic kidney disease.
It was alleged that an executive officer, a senior doctor at the hospital, attempted to coerce a medical services registrar into changing the date of death on Mr Reid’s death certificate, contrary to The Criminal Code s 85(d), and the Commission approved the matter for preliminary investigation on 7 October 2022.
The Commission has completed its investigation, which included a private examination and the review of a range of documents. No serious misconduct was identified in relation to the allegation and the Commission will take no further action.
“However, the investigation did highlight a misconduct risk in relying on paper records [and] it is now a matter for Rockingham General Hospital to manage that risk,” the Commission noted in its report.
“This investigation serves an important reminder for all public sector agencies whose operations have a reliance on hard copy or manual forms of record keeping…
“While electronic medical records can be costly to implement and maintain in the hospital system, electronic records offer better security and an audit trail of access. The management of a misconduct risk is a matter for the RPG.”
The Commission also pointed out that workplace conflict was common and could be constructive if managed well.
“A junior doctor may find it stressful, or intimidating being approached directly and repeatedly by a member of the hospital executive,” the CCC said.
“Correctly, as he had concerns, the registrar sought advice and notified the coroner, [and] in the Commission’s opinion the registrar was an honest witness whose testimony was credible.
“However, taken at its highest the evidence does not reach the threshold of a reasonable suspicion of serious misconduct.
“The evidence does not establish that the senior doctor attempted to coerce the registrar to change the date of death on Mr Reid’s death certificate – the senior doctor was entitled to ask the registrar to consider a change of date; the registrar was entitled to decline.”
During the investigation the CCC found that on the morning of 5 September 2022 the medical emergency team (MET) was called when Mr Reid’s heart rate dropped below 40 and by the middle of the day, the treating team determined that having tried all interventions Mr Reid was not improving, and he was transferred to the palliative care team with the family’s permission.
At 10.14 pm on the same day, nursing staff made the next entry in the integrated progress notes, recording: ‘Handed over by afternoon staff, pt [patient] passed away on handover at 2120 hrs. Contacted mother (NOK) to advise, awaiting doctor certify, family will come in soon.’
The Commission investigated why the extinction of life criteria was not documented when assessing cessation of life, rather than whether the Mr Reid had passed away at the time death was pronounced.
RPG’s clinical practice standards require that either a doctor or nurse assess and document cessation of life. However, only nurses at RPG’s Murray District Hospital (MDH) are required to undertake this responsibility because there are no doctors available at MDH after hours, and in practice, a doctor will determine life extinct at RGH.
After attending the evening handover meeting on Mr Reid’s ward, on 6 September 2022, a resident medical officer was advised by one of the nursing staff that he had passed away. She informed the nurse she still had to complete the death certification paperwork for the other patient and requested they contact the night team to review Mr Reid.
This did not occur, though whether due to an oversight or a breakdown in communication, the Commission was satisfied there was no serious misconduct involved.
A registrar who had been involved in Mr Reid’s medical care gave evidence that he last saw Mr Reid alive between 7.00 pm and 8.00 pm on 5 September 2022 when he walked past Mr Reid’s room and observed him take a breath.
The first he became aware that Mr Reid had passed away was when he was asked to complete the death certification on the morning of 6 September 2022, but by this time, Mr Reid’s body had been taken to the mortuary.
The registrar attended the mortuary in the company of two patient care staff, to examine the body and, concerned his findings were inconsistent with a person who was deceased on arrival at the mortuary, he discussed his observations with the palliative care team and a member of the RPG executive.
He said they discussed this possibility, other explanations for his observations and whether the death needed to be reported to the coroner.
The registrar explained it was agreed his findings did not alter the cause of death and he would complete the paperwork with the time that he reviewed the body recorded as the time he certified death.
He subsequently completed the Life Extinct Form, Death in Hospital Form and Medical Certificate of Cause of Death, recording the date of death as 6 September 2022 from decompensated heart failure.
The registrar gave evidence that he also handwrote two sets of notes as a record of what had occurred. One set were clinical notes which he placed on Mr Reid’s patient file, with the other to inform the registrar’s head of department, which covered the events of the day as well as workload statistics at that time.
The registrar placed these notes in the head of department’s desk drawer on his instructions, and the CCC noted that while these notes were recovered as evidence, the notes from Mr Reid’s patient file could not be located.
Without the second set of notes from the desk drawer, there was no contemporaneous record of the registrar’s findings from the mortuary and no record on the patient file to indicate anything untoward about the death certification process.
The Commission heard evidence that RGH was undergoing a reaccreditation process around the time that Mr Reid died, and the investigation concluded that no public officer had engaged in serious misconduct by destroying the notes, which constituted a patient record.
However, the registrar also gave evidence that a couple of weeks after Mr Reid died, a ward clerk informed him the funeral home had enquired whether the date of death could be changed on the paperwork as it was incorrect.
The registrar told the ward clerk the matter had been escalated to executive and needed to be discussed with them.
The registrar described subsequently being contacted three times by a senior doctor with respect to Mr Reid’s death to ask if he would change the date of death to 5 September 2022 to avoid distress to Mr Reid’s family.
The registrar confirmed this was a suggestion, rather than a directive, before declining to change the date as it was not when he had certified death and there was no written record of the nurse coordinator’s assessment.
The first two calls took place on 19 Sept 2022 his evidence confirmed that by the third conversation, on 30 September, there was still no direction from the senior doctor to change the date and the senior doctor accepted his response.
However, in his response to a draft of this report, the senior doctor denied asking the registrar to change the documented date of death and stated the purpose of the first conversation was to determine why the date on the death certificate was different from the date the family saw Mr Reid.
The purpose of the subsequent telephone call was to advise the registrar that Mr Reid had, in fact, been confirmed as deceased on 5 September 2022.
The third occasion occurred on the morning of 30 September 2022, when the registrar was at home after a busy night shift and received a call from the senior doctor on his mobile phone to enquire how he was coping.
They discussed Mr Reid’s care, and the registrar said that he had the impression from the call that the senior doctor wanted the date of death changed.
In his response to the draft report, the senior doctor stated the sole purpose of this call was to undertake a welfare check on the registrar and there was no discussion regarding Mr Reid’s death certification.