A 49yearold Bacchus Marsh father of five died after spending 12 hours at Geelong Hospital with a ruptured spleen, a coroner ruled yesterday.
But Ron Saines said it would be “inappropriate” for him to make recommendations to the hospital despite finding it had failed to run a CT scan on Ronald Hutchinson, which would have detected the injury.
Mr Hutchinson arrived at the hospital at 12.45am on May 7, 2005, after falling three metres down stairs at a relative’s holiday home in Anglesea. He died at the hospital around midday.
Mr Hutchinson’s widow, Jenny, and four of her children attended court to hear the ruling yesterday.
She said she was grateful the inquest was complete.
“His family will never recover from this but we appreciate the process,” Ms Hutchinson said.
“But this isn’t closure.”
Mrs Hutchinson said doctors had missed “many” opportunities throughout the night to detect her husband’s injury. Failure to run a CT scan ordered at 10am took away his “last chance”, she said.
“Ron must have been in horrible pain and he was not the type of person to complain.”
Mrs Hutchinson said she would never forgive herself for not being with her husband when he died.
“I spoke to the hospital in the morning and they gave me no sense of urgency,” she said.
“He was dead when we arrived to pick him up and take him home.”
Mr Saines found that the spleen injury caused a heart attack that killed Mr Hutchinson.
Mr Saines said it was unclear whether resuscitation attempts at the hospital had increased bleeding from Mr Hutchinson’s spleen.
The Hutchinson family’s lawyer, Dimitra Agiannitopoulos, said the hospital had initiated “systematic changes” because of the death, including addition of an onduty surgical registrar who could run CT scans during the night.
She said the family would sue over Mr Hutchinson’s death.
A Barwon Health spokesperson said the organisation had “noted” the coroner’s report and was “in agreement with its findings”.