The Victorian Coroner has found that a Ballarat medical specialist contributed to complications that caused the death of an 82-year-old Scarsdale man.
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Kevin O’Keeffe was admitted to Ballarat Health Services on January 31 last year to look for the cause of ongoing anaemia and underwent a gastroscopy and colonoscopy which found large vascular malformations in the gut that were bleeding.
Later that day Mr O’Keeffe underwent an electrosurgery procedure known as an argon plasma coagulation to stop the bleeding.
The next day after his condition deteriorated Mr O’Keeffe had emergency surgery which found several injuries to his bowel.
Despite treatment his condition continued to worsen and he died in the Ballarat Base Hospital ICU on February 5.
Reviewing the case and the BHS investigation, coroner Audrey Jamieson found the injuries to Mr O’Keeffe’s bowel were “full thickness burns and perforations due to the prolonged application of the APC”.
“I find that the technique adopted during the procedure directly contributed to the complications experienced by Mr O’Keeffe, a man already compromised by a number of pre-existing medical conditions,” the report said.
The coroner found the doctor had been trained on the instrument “however that training had not included techniques” and recommended the Therapeutic Goods Administration, which regulates medical products, review the death and consider whether the instrument’s manufacturer had “met relevant principles in relation to the operation of the system”.
BHS also conducted its own investigation after Mr O’Keeffe’s death.
“BHS conducted a thorough investigation and has implemented measures and procedures to reduce the future risk of similar complications occurring,” they wrote in a statement.
“Ballarat Health Services deeply regrets the circumstances which lead to the death of Kevin Patrick O’Keefe in February 2017, which have been released as part of the Coroner’s investigation.
“The medical specialist involved is a fully qualified and credentialed physician who had met all training requirements at the time.”