A TEENAGE footballer who died while in a home-based care program after undergoing major surgery was not returned to hospital despite warnings of agonising pain in the days before his death.
On the morning Andrew ‘‘Happy’’ Gilmore, of Werribee, died on May 22, 2009, administrators from the “Hospital in the Home” program told the 17-year-old’s parents to give him painkillers and wait an hour to see if he felt better.
The Coroner’s Court heard an ambulance was not dispatched until staff received a third phone call saying Andrew was struggling to breathe.
A three-day coronial inquest that began on Wednesday is scrutinising the management of post-surgical patients in the The Alfred hospital program, under which about 60 inpatients stay at home and receive daily nurse visits.
Andrew died after being injured playing for Glenorden under-18s in the Western Region Football League in May 2009.
He was rushed to Werribee Mercy after a blow to his sternum in a marking contest and transferred to The Alfred to have part of his pancreas removed.
Doctors told his family he would be in hospital for up to three months, but he was released on May 19, 10 days after surgery.
His mother, Irene Gilmore, told the inquest she thought it was “strange” that her son had been allowed to leave hospital so soon after his operation.
She said Andrew had not been eating well and suffered pain on May 21 due to bleeding caused by the removal of staples from his stomach.
Hospital in the Home nurse Margaret Candon visited Andrew’s Werribee house, noticing he had vomited up his painkillers. She instructed him to take the medication again and his pain eventually settled.
Ms Gilmore told the inquest that the next day, on the morning of her son’s death, she woke shortly after 5am to find him cramped in pain and vomiting.
She said she phoned The Alfred at 5.50am on a phone number provided by the Hospital in the Home program, but was told to wait for painkillers to take effect.
In a second phone call by his stepfather, Jayson Delia, 30 minutes later, the hospital was told Andrew’s pain wasn’t getting any better.
But the Hospital in the Home program’s clinical co-ordinator, after consulting with the gastrointestinal surgery registrar, told him to wait another hour for someone to call back to check on Andrew’s condition.
Mr Delia called the program co-ordinator at 7.53am, reporting Andrew was struggling to breathe, and the hospital dispatched an ambulance.
Paramedics found Andrew unconscious. By the time the ambulance arrived at Werribee Mercy Hospital, it was established he had been in cardiac arrest for an hour. Despite multiple doses of adrenalin, defibrillation and ventilation, he died shortly before 10.30am.
Under cross examination, Hospital in the Home representatives revealed that Andrew’s stomach pain was a “new pain” he had not suffered during his 10-day hospital stay following his surgery. But they believed the pain was not a major cause for concern.
The court heard that in 2009 there had been no clear policy regarding when a patient’s level of care should be increased and what should prompt a return to hospital.
The inquest, before Coroner Kim Parkinson, continues.
