A CORONER said yesterday he was unable to say if Wagga man Ross Inch would have survived car crash injuries but for the incorrect placement of a cannula into his chest by a paramedic.
Findings of an inquest into the death of 38-year-old Mr Inch were handed down by magistrate Tony Murray.
Mr Inch, a popular registered nurse in Wagga Base Hospital’s emergency department and father of three girls, died on August 16, 2009, after being involved in a motor vehicle accident on Yarragundry Road west of Uranquinty.
An uncle, 52-year-old Ken Pettifer, was a passenger in a utility being driven by Mr Inch and died at the scene of where the ute mysteriously left the road and hit a tree.
The inquest heard that in trying to save Mr Inch’s life, senior paramedic Eamonn Purcell inserted two cannulai into Mr Inch’s chest at the accident scene under trying circumstances and correctly followed NSW Ambulance Service protocol for a procedure which Mr Murray said was so unusual that even a highly-qualified paramedic such as Mr Purcell might never perform it in the course of their career.
One cannula pierced Mr Inch’s heart, resulting in Mr Inch swearing, blood spilling from the end of the catheter and an abnormal heart rhythm being detected on a monitor.
Paramedics at the scene were greatly concerned about these signs, but the inquest heard they did not pass the information on to trauma staff at Wagga Base Hospital when they handed an unconscious Mr Inch over to them.
Surgeon Stephen Jancewicz, who operated on Mr Inch, told the inquest had he known this information he would have explored Mr Inch’s left chest first and repaired the heart.
“One … area of concern was the lack of communication between the treating paramedics and the specialist trauma team waiting at (the) Wagga hospital,” Mr Murray said.
Mr Murray said there was substantial disagreement among the medical experts who gave evidence at the inquest about what effect the insertion of the cannula had on Mr Inch’s chances of survival.
“I am of the view that I am unable on the basis of the evidence given by such experts to form an opinion on the issue.”
Mr Murray said a matter that caused him a great deal of concern was the exchange of treatment information by the paramedics to the treatment team, especially the reactions of Mr Inch to the insertion of the cannula.
“From an external lay observer, I found it incredible that detailed records were not kept of such important information,” Mr Murray said.
“It appears from the other expert evidence that this behaviour is commonplace in trauma units in New South Wales.”
Mr Murray said he was satisfied Mr Purcell under extremely difficult circumstance cramped conditions in the back of an ambulance and Mr Inch thrashing around followed the then applicable protocol of inserting the cannulai.
“It is common ground between all the experts that the decision of Mr Purcell to undertake such a procedure in the light of the physical injuries sustained by the deceased could not be criticised and that such procedure was completed against a very, very difficult background and chain of events,” the coroner said.
“I am satisfied that such procedure was undertaken by Mr Purcell as he formed the view … that such procedure was necessary to save the life of Mr Inch, but to everyone’s great regret and sadness Mr Inch subsequently died.”
Following Mr Inch’s death the Ambulance Service introduced a new protocol for inserting cannula into the chest of patients.
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