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STATE CORONER’S COURTOF NEW SOUTH WALES Inquest:Inquest into the death of Kelvin MOULDSHearing date:30 March 2021Date of findings:16 April 2021Place of findings:NSW State Coroner’s Court – LidcombeFindings of:Magistrate Carmel Forbes, Deputy State CoronerCatchwords:CORONIAL LAW – cause and manner of death – care andtreatment – removal of CVC – delirium-hospital systemchangesFile number:2016/75759 Representation:Mr S A Beckett, Counsel Assisting, instructed by Mr VMusico, Department of Communities and Justice.Mr B Bradley instructed by Ms H Allison, Crown Solicitor’sOffice, representing St Vincent’s Hospital.Findings:Kelvin Moulds died of hypoxic encephalopathy on 9March 2016 at St Vincent’s Hospital, Sydney, New SouthWales, in circumstances arising from a cardiac arrestfollowing his self-removal of the central venous catheterfive days before.Non-publication order:Pursuant to section 74(1)(b) of the Coroners Act 2009 Iorder that any evidence tending to identify the streetaddresses, email addresses and phone numbers ofmembers of the Moulds family not be published. 1Findings in the Inquest into the death of Kelvin MouldsIntroduction1. Mr Kelvin Moulds was a 61-year-old man who died at St Vincent’s Hospital, Sydneyon 9 March 2016. His death occurred only weeks after he received a bilateral lungtransplant at the hospital by one of Australia’s leading lung transplant teams.2. Mr Moulds died of hypoxic encephalopathy. The crucial event that led to his deathwas his own removal of a central venous catheter (CVC) from his right jugular vein inthe early hours of 4 March 2016. He went into cardiac arrest. He did not regainconsciousness and sadly passed away five days later.3. A coroner’s primary role is to investigate and make findings as to the identity of thedeceased person, the date and place of the death, and the manner and cause ofdeath. A further role for a coroner is to assess whether there has been anappropriate response to an unexpected death and whether more needs to be doneto protect others from a similar death.Facts4. In July 2015 Mr Moulds was diagnosed with bilateral idiopathic pulmonary fibrosisby Dr Saurabh Gupta at the Nepean Lung and Sleep Centre. He had a 2.5-year historyof productive cough, without haemoptysis,1 and shortness of breath. Dr Guptarecorded that Mr Moulds had a history of reflux or asthma and stated he was an exsmoker and denied any asbestos exposure.2 He also suffered from glaucoma, type 2diabetes mellitus, and mild obstructive sleep apnoea.35. Mr Moulds was referred to St Vincent’s Hospital in September 2015 for lungtransplant assessment4 and was placed on the organ donation waiting list inNovember 2015.51Coughing up of blood.2Letter of Dr Saurabh Gupta to Astley Medical Centre dictated 1 July 2015, Astley Medical Centre Clinical Notes – CoronialBrief Tab 42. All subsequent footnote references to tabs are references to Coronial Brief tabs.3Letter of Dr Saurabh Gupta to Astley Medical Centre dictated 28 October 2015, Astley Medical Centre Clinical Notes – Tab424Referral letter of Dr Saurabh Gupta to Professor Alan Glanville dictated 2 September 2015, Astley Medical Centre ClinicalNotes – Tab 425St Vincent’s Hospital, Medical Records, Progress Notes – Tab 312Findings in the Inquest into the death of Kelvin MouldsThe bilateral lung transplant6. In the early hours on 19 February 2016 Mr Moulds was informed that lungs hadbecome available to him for transplant and that he needed to attend St Vincent’sHospital.6 Mr Moulds was admitted to St Vincent’s Hospital at 0315 hours via theemergency department at St Vincent’s Hospital.7 On admission Mr Moulds was 97kilograms and 177cm.7. Mr Moulds was transferred to the surgical ward where he was prepared for surgery,which was subsequently performed by Dr Mark Connellan.8 The surgery commencedat approximately 1200 hours and was completed at approximately 1900 hours.9 Theoperation performed was a bilateral sequential single lung transplant (BSSL).8. As part of the operative process, a 4-lumen10 central venous catheter (CVC) wasinserted into Mr Moulds’ right internal jugular vein.119. Post-operatively, Mr Moulds was admitted to the intensive care unit atapproximately 1930 hours on 19 February 2016 (Day 0), where he was sedated andintubated.12 Mr Moulds was also on venous extracorporeal membrane oxygenation(ECMO).1310. During Mr Moulds’ ICU admission he had impaired lung compliance, lactic acidosis,intermittent elevated white cell count, pericarditis with ST elevation on leads 4, 5, 6 I& II, intermittent paroxysmal atrial fibrillation, thrombocytopenia, bi-basal collapseand copious secretions, sputum plugs in the right and left lower bronchus,reperfusion oedema in the mid and lower zones of both lungs, and moderate leftlower lobe atelectasis.6NSW Police Force, Report of Death to the Coroner completed 9 March 2016 – Tab 17St Vincent’s Hospital, Medical Records, Anaesthetic and Recovery Record – Tab 29o8St Vincent’s Hospital, Medical Records, Operative Report – Tab 29q9St Vincent’s Hospital, Medical Records, ICU Flow Charts – Tab 3710A lumen is a line which allows for the delivery of medication or fluid to a patient through the catheter.11St Vincent’s Hospital, Medical Records, Anaesthetic and Recovery Record – Tab 29o12St Vincent’s Hospital, Medical Records, ICU Flow Charts – Tab 3713St Vincent’s Hospital, Medical Records, ECMO Observation Charts & Progress Notes – Tab 33. ECMO isan extracorporeal technique of providing prolonged cardiac and respiratory support to persons whose heart and lungs areunable to provide an adequate amount of gas exchange or perfusion to sustain life.3Findings in the Inquest into the death of Kelvin Moulds11. On 20 February (Day 1 post-operatively) it was discovered that the donor lungs had aklebsiella infection. Mr Moulds was prescribed antibiotics.12. On 22 February (Day 3) the decision was made to cease ECMO and Mr Moulds wasde-cannulated at approximately 1300 hours.14 A cytomegalovirus (CMV)15 wasdiscovered and Mr Moulds was prescribed anti-viral agents.1613. On 23 February (Day 4) Mr Moulds was extubated.17 Post-extubation, Mr Mouldswas placed on high-flow nasal prongs (HFNP) for the provision of oxygen and wasnoted to be hypoxic.18 Mr Moulds was prescribed Oxycodone PRN,19 Paracetamol,and OxyContin for pain that day.14. On 26 February (Day 7) Mr Moulds was transferred to a High Dependency Ward.2015. Between 26 February and 2 March (Days 7 and 12) Mr Moulds had persistentperiods of shortness of breath, required supplemental oxygen and experienceddifficulty sleeping and lying flat.21 He had anxiety on 1 and 2 March (Days 11 and 12).16. Mr Mould’s treatment post-operative treatment was overseen by two experiencedspecialists in lung transplantation, Dr Mark Benzimra and Dr Monique Malouf, whoalternated treatment depending on who was on duty.17. When Dr Malouf saw Mr Moulds on 1 March 2016 (Day 11) she noted that therewere a lot of secretions as a result of a bronchoscopy and that he was “spaced out”and was dysarthric and had slurred speech. She reduced his Targin as a result. Shenoted also that he had reduced breath sounds at the right base of his lungs and thatdiaphragm palsy should be considered.18. She further noted that the diaphragmatic palsy which he was experiencing was likelyto be because of damage to the phrenic nerve during the surgery. He was alsoplaced on an anti-viral medication. She says in her statement that the diaphragmatic14St Vincent’s Hospital, Medical Records, ECMO Observation Charts & Progress Notes – Tab 3315CMV is a common viral infection which can be latent and arise in the context of a suppressed immune system.16Ganciclovir was the medication administered.17That is, the tube was removed. St Vincent’s Hospital, Medical Records, Progress Notes – Tab 29d18That is, have low oxygen. St Vincent’s Hospital, Medical Records, Progress Notes – Tab 29d19As needed.20St Vincent’s Hospital, Medical Records, Progress Notes – Tab 29d21Dr Benzimra had advised him to sleep upright for better lung function – Tab 11 at [39].4Findings in the Inquest into the death of Kelvin Mouldspalsy was not likely to resolve in the short term but may eventually resolve withtime. She said that Dr Benzimra had recorded that Mr Moulds was to be positionedat night ‘not flat’, which was appropriate for his condition.2219. Dr Benzimra last saw Mr Moulds on 2 March 2016 (Day 12). He noted in particularthat there was palsy in his lung and there was right hemidiaphragm paralysis; that hehad not tolerated CPAP that night and was not sleeping through the night. He alsosaid that there were reduced breath sounds at base, that Mr Moulds’ observationswere otherwise stable, he was afebrile and well on room air. The plan was to referhim to the sleep team perhaps for BIPAP, he was not to have sleeping tablets and“position at night. Not flat”.20. Dr Benzimra was of the view that by 2 March 2016 Mr Moulds seemed to have beenimproving, his observations were stable and he was well on room air. The decision tocommence him on CPAP on 1 March 2016 by the sleep team was done in the contextof his diaphragm not working properly and to assist him with breathing. Dr Benzimrawanted the sleep team to reassess him and see if they could adjust the pressure tomake him more comfortable with CPAP. He was also keen to have input frompsychology to assist with sleeping and tolerating ventilation efforts. In particular healso directed that Mr Moulds was to be positioned upright at night to assist withventilation and to reduce the risk of aspiration. 233 March 2016 (Day 13)21. On Day 13 at 0700 hours RN Johnson recorded that Mr Moulds was alert andoriented but frustrated overnight due to lack of sleep. Temazepam used overnightwas noted to have had no effect.2422. Between 0700 and 0900 hours Mr Moulds was seen by the Lung Transplant Team ledby Dr Malouf and including Dr Koliarne Tong.22Statement of Dr Monique Malouf – Tab 12 at [18]-[24]23Statement of Dr Mark Benzimra – Tab 11 at [38]-[40]24Statement of RN Elham Asgary – Tab 23 at [4]5Findings in the Inquest into the death of Kelvin Moulds23. Dr Malouf observed that the bronchial wash revealed no bacterial growth and shesaid she was able to then change from intravenous to oral antibiotics. This issignificant because the decision to move him from intravenous medication to oralmedication meant that if other IV use had ceased, his CVC could then be removed.24. The clinical note, under “Issues” and “Plan”, recorded “CVC out” twice.25. Dr Malouf also said that Mr Moulds was very anxious following the transplant andwas a little bit delirious, which she said is not uncommon in transplant patients. Shethought that delirium would also have had some effect on his decision making at thetime. She thought this might in part be due to his poor sleep and also referred himto the sleep team so that he could be given CPAP. She also wanted the psychologistsinvolved to assist Mr Moulds with his anxiety and sleeping.26. Dr Malouf noted Mr Moulds had diaphragmatic palsy and spoke to him about theimportance of sitting up at night because of the physiological benefits. Dr Maloufobserved that Mr Moulds’ bronchial wash contained no bacterial growth andchanged his antibiotics from intravenous Cefotaxime to oral Augmentin Duo Forte. 2527. At 0900 hours respiratory and sleep physician Dr David Abelson reviewed MrMoulds, who complained that his insomnia was due to pain and discomfort. Hisarterial blood gas (ABG) from the previous evening showed a mild respiratoryalkalosis with pH 7.47 (normal 7.35-7.45), low arterial partial pressure of carbondioxide (PaCO2) of 32 mm of mercury (mmHg) and low, but adequate, arterial partialpressure of oxygen (PaO2) at 64 mmHg. His morning ABG on 3 March 2016 wassimilar, pH 7.43, PaCO2 36, PaO2 66, indicating no substantial change in gas exchangeovernight. Mr Moulds continued to state he did not want to use CPAP or BiPAP.2628. Dr Abelson looked at the oximetry trace from the previous night and found no clearevidence of significant sleep disorder.25Statement of Dr Monique Malouf – Tab 12 at [28]-[30]26Statement of Dr David Abelson – Tab 156Findings in the Inquest into the death of Kelvin Moulds29. At 0930 hours RN Elham Asgary reviewed Mr Moulds and recorded he wasbreathless and unwell.2730. At about 0945 hours physiotherapist Mr Darryl Beddoe attended and noted MrMoulds was “drowsy/confused/cannot talk in full sentences”, his blood pressure was150/71 and oxygen saturation on room air was 92%. He assessed Mr Moulds asdeteriorating and asked for a review by the lung transplant team.2831. At the time of the review by the physiotherapist, the CVC was attached. RN Asgaryresecured the CVC and changed the dressing on the line. RN Asgary was unaware ofthe order to remove the CVC.2932. At some time after their morning round, Dr Tong informed Dr Malouf that MrMoulds’ CVC was still in situ. Dr Malouf confirmed her order that it be taken out andsent Dr Tong back to the ward.3033. Shortly after 1000 hours Dr Tong attended on Mr Moulds and found him drowsy buteasily woken and oriented to time and place. His physical observations were stablebut Dr Tong suspected he was delirious.3134. Dr Tong asked RN Asgary why the CVC was still in place. RN Asgary said that she didnot wish to remove it at that stage because the patient was unwell and neededaccess.32 RN Asgary was of the impression that “the registrar” had approved of thatapproach.35. Dr Tong then spoke with Dr Malouf and decided to investigate for any contributingfactors to his altered mental state. She ordered a non-contrast CT brain, chest x-ray,an ABG to measure carbon dioxide level, and added thyroid function tests to theday’s blood tests.3327Statement of RN Elham Asgary – Tab 23 at [9]28St Vincent’s Hospital records, Progress Notes – Tab 29d29Statement of RN Elham Asgary – Tab 23 at [10]-[12]. No criticism is made of RN Asgary in this respect.30Statement of Dr Monique Malouf – Tab 12 at [32]31Statement of Dr Koliarne Tong – Tab 16 at [25]-[26]; St Vincent’s Hospital records, Progress Notes – Tab 29d32Statement of RN Elham Asgary – Tab 23 at [10]-[12].33Statement of Dr Koliarne Tong – Tab 16 at [25]-[26]7Findings in the Inquest into the death of Kelvin Moulds36. The results were later reviewed by Dr Tong who observed there were noabnormalities or changes to account for the suspected delirium.3437. At 1250 hours RN Asgary noted that the patient “is alert and oriented, sleeping mane[morning], clinical review, ABG [arterial blood gas], RA sat [saturations on room air]92% increased respiratory rate to 28. Settle down [with] reassurance & making himcalm.” Mr Moulds’ wife came and visited him.3538. At about 1430 hours RN Shin Chung took over from RN Asgary and received anindividual patient handover from her. RN Asgary advised that Mr Moulds had beenmoderately unwell during the morning shift and that his respiratory rate was high.RN Chung understood that the doctor had asked that the CVC be removed but, givenhis condition, RN Asgary was concerned it was “a bit risky”.3639. RN Chung understood that RN Asgary had obtained the approval of a member of theLung Transplant Team to leave the CVC in place until the next day.3740. At 1445 hours Mr Moulds was reviewed by Dr Tong and Dr Senthen Rajalingam fromthe Lung Transplant Team. Dr Tong reviewed the earlier entry by psychologist, DrMartijn, and noted that delirium was suspected. Mr Moulds appeared alert andbrighter. They reviewed and discussed the brain CT and chest x-ray. Dr Tong notedthe CVC was still in place and requested it be removed by nursing staff thatevening.38 The clinical note reads:“Pt feeling ok, falling asleep during the day – BO, nil reflux. CT brain – nilacute pathology, prominent ventricles. CXR – nil significant change. O/E: HR –70, BP – 120/70, Sp O2 – 97% 2LNP. Alert, appeals well – A/E both bases.Plan: await further input from sleep team. CVC out.”41. At 1445 hours Mr Moulds’ oxygen saturation was recorded by Lung Transplant teamas 97% at 1445 with 2 litres of oxygen by NP up from 94% at 1400.34Ibid. The CT report said “no detectable ischaemia”.35Statement of RN Elham Asgary -Tab 23 at [14]; St Vincent’s Hospital records, Progress Notes – Tab 29d36Statement of RN Shin Chung – Tab 21 at [7]37Statement of RN Shin Chung – Tab 21 at [6]-[9]38Statement of Dr Senthen Rajalingam – Tab 14 at [22]; statement of Dr Koliarne Tong – Tab 16 at [27]-[30]; and StVincent’s Hospital records, Progress Notes – Tab 29d8Findings in the Inquest into the death of Kelvin Moulds42. It is not clear whether a registrar had in fact consented to a delay in removal of theCVC. RN Asgary believed that was the case but the medical practitioners do not recallsuch consent being given and the clinical note at 1445 supports that interpretation.It is, however, not possible to determine whether this was as a result of amisunderstanding or poor communication about the removal of the CVC or whetherthere was a simple mistake by either medical or nursing staff.43. Towards the end of the workday, Mr Moulds was seen by Psychiatrist, Professor KayWilhelm, from the Consultant Liaison Psychiatry Service. Professor Wilhelm attendedand found Mr Moulds distressed, delirious, and breathless. His Montreal CognitiveAssessment (MoCA) score had declined to 20/30, a significant decrease on his pretransplant score and in this context was considered a further indicator of delirium.Prof Wilhelm recommended 5mg of Haloperidol (an anti-psychotic) be given thatevening. Prof Wilhelm asked CNC Cooper to review the following morning.3944. As Prof Wilhelm was not part of the treating team, the Haloperidol was onlyrecommended for consideration by that team.4045. Dr Rajalingam raised Professor Wilhelm’s recommendation for Haloperidol with DrTong while they were completing the evening ward round. Dr Rajalingam said that DrTong wanted to speak with a consultant about the recommendation beforecharting.4146. It is not known whether Dr Tong did speak with the consultant that evening and ifshe did, the nature of the consultant’s response. In any event, the Haloperidol wasnot charted and was not administered to Mr Moulds.47. At 2130 hours RN Raven took over the nursing management of Mr Moulds. Athandover, she was advised that Mr Moulds was two weeks post-transplant, hadexperienced anxiety and delirium, and had been transferred to bed 13 in the SleepStudies Unit to undergo investigations.4239Statement of Professor Kay Wilhelm – Tab 9 at [12]-[17]; St Vincent’s Hospital records, Progress Notes – Tab 29d40Ibid. at [17]41Statement of Dr Senthen Rajalingam – Tab 15 at p.5(2)(a)42Statement of RN Sharyn Raven – Tab 25 at [4]-[6]9Findings in the Inquest into the death of Kelvin Moulds48. At 2200 hours Dr Richard Hanlon commenced his shift. The usual practice was for ahandover to be conducted between the day rapid response team, including themedical registrar. Dr Hanlon was not advised of any jobs relating to Mr Moulds andwas not asked to review him.4349. That evening Mr Moulds was transferred to the Sleep Studies Unit but was noted tohave “appeared anxious” and refused the sleep study. He was transferred back tothe ward.444 March 2016 (Day 14)50. At 0200 hours on 4 March 2016 Mr Moulds became anxious. RN Raven reassuredhim and records the following observations:“Blood pressure 130/81, Heart rate 89 bpm and regular, Respirations 20 bpm,Oxygen saturations 91% on room air.”51. RN Raven applied oxygen 2L via nasal prongs and his oxygen saturations increased to97%. With further reassurance, Mr Moulds settled. He was alert and oriented to timeand place and moving from his bed to the chair without assistance.4552. At about 0330 hours RN Raven was attending to other patients near Mr Moulds’ bedwhen she heard a noise. A nearby patient was found on the floor near the bathroomhaving fallen over. The patient was escorted back to bed and the night RMO wasnotified. All patients nearby, including Mr Moulds, were woken by the noise and thelights. They were checked and reassured by nursing staff.4653. At about 0400 hours Mr Moulds removed the CVC from his right internal jugular veinfor reasons which are unknown.4743Statement of Dr Richard Hanlon -Tab 17 at [6]-[7]44St Vincent’s Hospital, Medical Records, Progress Notes – Tab 29d45Statement of RN Sharyn Raven – Tab 25 at [9]-[10]46Ibid. at [11]-[12]47Ibid. at [13] and statement of RN Fiona Cattell – Tab 28 at [6]-[10]10Findings in the Inquest into the death of Kelvin Moulds54. The removal of a CVC is a procedure only undertaken in NSW hospitals by qualifiedmedical or nursing staff because of the danger of creating an air embolism, whichmay in turn lead to a cardiac arrest.55. RN Sharyn Raven and RN Fiona Cattell were nearby at the time.56. Mr Moulds sat upright while holding out the CVC in the direction of the nurses andsaid, “What do I do with this?” or “What’s this?”.57. RN Cattell noted that the CVC was still attached to his neck by the anchoring suturesbut there was no bleeding.48 She went to the treatment room to obtain a stitchcutter and dressing. Together with RN Raven, she removed the suture to seal thewound before applying the dressing. An occlusive dressing was placed on the CVCsite on Mr Moulds’ neck. No bleeding was noted. Mr Moulds was alert at this time.4958. Mr Moulds was asked to lie flat on his back and placed on bed rest. Observationswere recorded as follows:“Blood pressure 134/84. Heart rate 100 bpm and regular. Respirations 20bpm. Oxygen saturations 100% on oxygen 2L via nasal prongs”59. RN Raven noted later that Mr Moulds at this point was “Patient on bed, Tilted”,which she clarified as lying partially on his left side.5060. RN Raven remained in the room. She saw Mr Moulds looking in her direction and heasked her when he could get up and move around.61. While RN Raven was attending to another patient, she noticed Mr Moulds had gonequiet. She turned to check he was not trying to get up and saw that he appeared tobe looking at her, but was still. She went to Mr Mould’s bedside and spoke to himbut he did not respond. She called out to Dr Hanlon, who was still attending to thepatient who had fallen.5148Statement of RN Fiona Cattell – Tab 28 at [8]49Statement of RN Fiona Cattell – Tab 28 at [6]-[10]50Supplementary statement of RN Sharyn Raven – Tab 25 at [7]-[8] and St Vincent’s Hospital, Medical Records, ProgressNotes – Tab 29d51Statement of RN Sharyn Raven – Tab 25 at [12]-[23]11Findings in the Inquest into the death of Kelvin Moulds62. CPR was commenced as it was apparent Mr Moulds’ heart had stopped.63. Dr Hanlon said he was reviewing a patient on the bed adjacent to Mr Moulds. Hefinished a conversation with the patient when he heard words to the effect of “Can Iget some help over here?”. When he turned around, he saw a female nursecommencing chest compressions on Mr Moulds. He went straight to Mr Moulds andbegan assisting the nurse. The Code Blue button was pressed. Within a few shortmoments of his arrival other nurses arrived. 5264. RN Raven later noted:“Patient on bed tilted – noted to become unresponsive – Dr in room startedCPR and called CODE BLUE.”5365. At 0425 hours the ICU Code Blue team arrived at Mr Moulds’ bed. They took overCPR from Dr Hanlon and the nurses present. Spontaneous circulation returned afterapproximately 15 minutes, six rounds of CPR and 800mcg of adrenaline.54 In a clinicalnote written later that morning, the ICU Fellow noted “Imp[ression]: air embolism”.66. Mr Moulds was readmitted to the ICU at 0449 hours and was sedated andintubated.55 A new right internal jugular CVC was inserted.5667. At 0705 hours Dr Stephen Morgan reviewed Mr Moulds. He noted a “presumptivediagnosis of air embolism post-impromptu CVC removal on ward, Arrest asdocumented”. Amongst other things he noted a Glasgow Coma Score of only 4. Hisimpression was “Post-asystolic arrest with best neurological response of non-specificmovements of all limbs. Pupils non-responsive. Cardiorespiratory supportrequirements not significant nor deteriorating.” He also remarked that “Needs TOE[transoesophageal echocardiogram] to assess for any residual gas in chambers, toexclude PFO [patent foramen ovale or a ‘hole in the heart’].5752Statement of Dr Richard Hanlon -Tab 17 at [8]-[10]53Supplementary statement of RN Sharyn Raven – Tab 25 at [4] and St Vincent’s Hospital, Medical Records, Progress Notes– Tab 29d54St Vincent’s Hospital, Medical Records, Progress Notes – Tab 29d55Ibid.56Ibid.57Statement of Dr Stephen Morgan – Tab 13 at [10] and St Vincent’s Hospital Medical Records, Progress Notes – Tab 29d12Findings in the Inquest into the death of Kelvin Moulds68. At 0730 hours Dr Tong attended the hospital early to review Mr Moulds in the ICU.She changed his oral transplant medications across to intravenous forms. She notedlow urine output suggesting he needed more IV fluids. She changed his antibioticsand commenced Ganciclovir as he was a CMV positive patient. She noted he neededa TOE [Trans Oesophageal Echocardiogram] to look for an air embolism.5869. At 1725 hours that day Dr Malouf noted the question as to whether there had beenan air embolism. She noted that “RV [right ventricle] dilation [left ventricle] no air, noPFO”.5970. The results from the TOE did not reveal that Mr Moulds had suffered from an airembolism.71. A later review of the TOE taken at the time by an expert radiologist also did notreveal that Mr Moulds had suffered from an air embolism.Subsequent events72. Mr Moulds’ neurological condition did not improve over the subsequent days.73. By the morning of 8 March 2016 (Day 18) Mr Moulds had shown no improvement inhis neurological status with a Glasgow Coma Score persistently of 3. An MRI of hisbrain revealed that he had suffered severe hypoxic brain injury. Mr Moulds’ familydecided to transition Mr Moulds to palliative care and he was extubated thatevening.6074. Mr Moulds sadly passed away at 1415 hours on 9 March 2016.Cause of death58Statement of Dr Koliarne Tong – Tab 16 at [32] and St Vincent’s Hospital Medical Records, Progress Notes – Tab 29d59St Vincent’s Hospital, Medical Records, Progress Notes – Tab 29d60Ibid.13Findings in the Inquest into the death of Kelvin Moulds75. A limited autopsy was performed on 15 March 2016.61 The forensic pathologistdetermined the cause of Mr Moulds’ death as hypoxic encephalopathy; however,the pathologist was unable to determine the underlying event which caused MrMoulds’ death.76. Statements were taken from nine of the treating medical practitioners at St Vincent’sHospital, including the specialists on the lung transplant team who were directlyinvolved with Mr Moulds care, and 11 registered nurses responsible for his care.6277. In addition, independent expert evidence was obtained from consultant anaesthetistand intensivist, Dr William O’Regan,63 and consultant radiologist, Dr James Christie64.78. Dr O’Regan stated, and his opinion on this point is not in dispute, that Mr Moulds’cardiac arrest on 4 March 2016 led him to developing hypoxic encephalopathy.79. Both experts looked to see if there was any evidence of an air embolism that mayhave caused the cardiac arrest. Both experts actively considered this possibilitybecause of the well-known association between the poor removal of a CVC and thedanger of developing an air embolism.80. Dr O’Regan considered the detailed clinical notes and comprehensive medicalrecords provided with respect to Mr Moulds, and could not detect any positiveevidence of an air embolism. Dr Christie closely examined all of the x-rays, CT scansand MRIs that were taken on or about the time of Mr Moulds cardiac arrest on 4March 2016. He could not see any evidence of an air embolism.81. Dr O’Regan said, ultimately, he could not exclude that an air embolism had occurredand that it was not unreasonable to assume that that was the likely cause of thecardiac arrest. However, he could not be conclusive in this regard and posited thatthe cardiac arrest may have also been caused by an anterior event, being respiratoryarrest caused by his poor respiratory condition. This condition was due, of course, tothe fact that he had undergone a bilateral lung transplant just two weeks prior.61Tab 462Tabs 9-2863Tab 764Tab 814Findings in the Inquest into the death of Kelvin Moulds82. Dr Christie concluded that although it was presumed, based on clinical course, thatMr Moulds had an air embolus, there were no positive findings in the imaging toconfirm that this had occurred.83. In all of the circumstances, I accept the expert opinion that a conclusivedetermination cannot be made as to what caused Mr Mould’s cardiac arrest.84. In those circumstances, the cause of death is best described as hypoxicencephalopathy arising from a cardiac arrest following self-removal of a CVC.Manner of Death85. The CVC that was inserted at the time of the lung transplant operation was still insitu some 14 days after. This was despite two instructions from the lung transplantconsultant at St Vincent’s Hospital to remove it. Dr Malouf clearly recorded in hernotes on 3 March 2016 that the CVC was to be removed, and when later that day shefound out from Dr Tong that the CVC was still in situ, she asked for Dr Tong to returnto ensure that the CVC was removed. Dr Tong later confirmed in a clinical note thatthe CVC was to be removed. However, it had not been removed by 4 March 2016.86. According to RN Asgary, she sought approval to leave the CVC in situ on the morningof 3 March 2016 because she was worried about Mr Moulds deteriorating and couldforesee the need to use a CVC.87. It is not possible for this Court, given the passage of time and the absence of anyother clinical notes by either a nurse or medical practitioner, to ascertain at this timewhether RN Asgary was able to obtain approval for this course of conduct. Dr Maloufstates that it is unlikely that she would have permitted the retention of the CVC insitu.88. What can be concluded is that there was a breakdown in communication on thisimportant issue between the medical practitioners and the nurses on duty.89. Mr Moulds woke up at about 0330 hours on 4 March 2016 when a neighbouringpatient fell and was attended to by nurses. At about 0400 hours Mr Moulds removed15Findings in the Inquest into the death of Kelvin Mouldsthe CVC from his right jugular vein himself. The removal was not seen and thecircumstances immediately prior to removal were not known.90. Delirium had been specifically noted by a number of practitioners during 3 March2016 and those responsible for Mr Moulds’ care had noted that he was delirious andthat it was likely to have been caused by a lack of oxygen. In particular, his saturationlevels were low when he was on room air.91. It is possible that Mr Moulds was in a state of delirium when he removed his CVC.92. However, shortly before his neighbouring patient fell, Mr Moulds had been givenoxygen and he was noted as being settled. It may have been that the sudden noise ofthe patient falling startled him, and this resulted in him being confused and pullinghis CVC line. It is not possible to make a conclusive finding as to why he removed hisCVC line.93. St Vincent’s Hospital has provided evidence of the changes that have been put inplace to address the possibility that Mr Moulds was suffering from delirium and thatthis had not been adequately treated. (See paragraphs 97 and following.)94. When Mr Moulds removed his CVC line, there were two nurses on duty nearby whowere able to attend to him promptly. According to Dr O’Regan, they tookappropriate action by dressing the wound that was caused as a result of the removalof the CVC and placing Mr Moulds in a supine position on his left-hand side. Thisaccords with the New South Wales Health Policy of 2011 for the removal of CVC,which requires patients to be in the supine position when a CVC is being removed,and for a period of 30 to 60 minutes after the removal.95. Dr O’Regan was not critical of the nurses taking this approach or for the treatmentthey adopted following the removal of the CVC. Dr O’Regan did say that whileplacing Mr Moulds, whose respiratory capacity was compromised by the lungtransplant, in the supine position was unavoidable; such a position was dangerousbecause of further compromise to his ability to breathe.16Findings in the Inquest into the death of Kelvin Moulds96. Dr O’Regan concluded that the nurses concerned took the appropriate step of tiltingMr Moulds following the removal of the CVC and the dressing of the wound. DrO’Regan made no adverse comments of the nurses in this regard and no criticism canbe made of the care and treatment of Mr Moulds once he removed the CVC.St Vincent’s Hospital Systems Changes97. St Vincent’s Hospital took Mr Moulds’ death very seriously and have providedstatements setting out the significant changes that have taken place since 4 March2016.98. RN Mark Young, clinical nurse coordinator, summarised the main changes in CVC useduring the period from 2016 to 2019 as follows:65a) There has been an active effort to minimise the use of CVCs in favour ofPeripherally Inserted Central Catheter (PICC) lines within St Vincent’sHospital. This is because PICC lines have fewer and smaller diameterlumens and are associated with lower air embolism risk.b) There is an active focus on the early removal of CVCs, especially in patientswith delirium. RN Young says there is an increased awareness that deliriumis an indicator for early removal of CVCs. Those operating under the policyare directed to the following warning:“consideration should be given to the presence of a femoral orinternal jugular CVC and air embolism risk, particularly in thedelirious patient in the ward setting. If delirium is suspected seniormedical review should occur with respect to removal of CVC andreplacement of lower risk device such as a PICC or peripheralcannula.” 6665Tab 6466St Vincent’s Hospital Vascular Access CVAD Removal (Non-Tunnelled) Protocol 2019 – Tab 64, Attachment MY-12,Section 4 Process17Findings in the Inquest into the death of Kelvin Mouldsc) RN Young says that as a general rule, the use of CVCs are now discouragedin the ward setting unless clinically demanded. ICU medical officers areasked to consider switching CVCs to a peripheral cannula or a PICC wherepossible before transfer to a ward setting. One of the advantages ofmanaging a CVC in ICU, as opposed to a ward setting, is the improvednurse to patient ratios. While ICU can provide 1:1 nursing, the ratiosincrease on the ward to 1:4-6 patients. Delirium has now been identified,according to RN Young, as an indicator for removal of CVC and is treated asa red flag for removal.d) There have been increased educational opportunities provided through inservice papers to nursing graduates. Training and accreditation haveimproved through the requirement to complete the MyHealth learningprogram run by the Health Education and Training Institute. Any currentnursing staff who have had a pause or gap in clinical practice are requiredto repeat their clinical competency.99. In 2020 further changes were made including the introduction of an updated CVADremoval policy procedure, which includes an update Central Venous Access Device(CVAD) Care Management Plan. The new protocol specifies that all CVADs must beremoved safely and without delay, noting specifically that delay in removal mayincrease the risk of CVAD related morbidity and mortality, and if there is not anaccredited staff member to remove the CVAD, there is now an escalation chain thatmust be followed.100. RN Young also pointed to a number of audits that have been conducted since 2016into post-insertion care of CVADs. He noted that in November 2017, there was animproved 96% compliance across St Vincent’s Hospital with insertion and postinsertion care. That compliance was about the same level in May 2018 wherecompliance was noted to be 95%. In November 2018, compliance was at 98% but inApril 2019, results fell slightly to 93%. RN Young then went on to say that he notedsome deficiencies in documentation at that stage and steps were taken to addressand improve this.18Findings in the Inquest into the death of Kelvin Moulds101. On 16 August 2019 New South Wales Health issued a new policy directive titledIntravascular Access Devices Infection Prevention and Control. It was acknowledgedin that document that CVADs pose a risk of air embolism in patients during insertionand removal and that public hospitals must have a process for the appropriate useand management of invasive medical devices to minimise the risk of device relatedinfection to patients. Shortly after the release of this new policy, St Vincent’sHospital convened an air embolism/CVAD care meeting coordinated by RN Youngand including a number of cardiothoracic surgeons, including thoracic physician, DrMalouf, who was involved in Mr Mould’s treatment.102. At the meeting some of the issues discussed were: the preferred site for CVCinsertion to reduce the risk of air embolism, a preference for early removal of CVCsin the intensive care unit (ICU) and before discharge to the ward, discussion as to theabsence of PICC removal related area embolism in literature to date, and the use ofthe Delirium Risk Assessment Tool to monitor delirium in ward patients andagreement that delirium was an adequate reason for removal of CVCs.103. As part of the review, RN Young referred to six patients who between 2014 and 2019experienced adverse CVAD events creating an air embolism, with three of thosepatients subsequently passing away. RN Young noted that five of the events involvedlung transplant patients, five of the events occurred on the ward as opposed to ICU,and three of the events involved delirium or behavioural issues. Mr Moulds’ case wasone of the events that was considered.104. RN Young noted that substantial changes had happened as a result of this particularreview, including consideration given to removing CVCs before discharge from theICU to award setting, reduction in the use of CVCs in preference to PICCs, anddelirium being now considered a red flag for removal of the CVC.105. St Vincent’s Hospital is accredited by the Australian Commission on Safety andQuality in Health Care and, as part of that accreditation, must meet two nationalsafety and quality health service standards which relate to delirium.19Findings in the Inquest into the death of Kelvin Moulds106. RN Joanne Taylor provided a statement67 setting out the changes to the monitoringof delirium in patients at St Vincent’s Hospital. In particular, she referred to a newplan known as the SVHN – Delirium Screening, Assessment, Prevention andManagement Plan of 9 September 2019.107. In 2017 it was identified that St Vincent’s Hospital had rates of delirium which werehigher than other Peer A1 hospitals. This led to substantial work being undertaken toaddress this issue and to implement the above-mentioned 2019 plan. This includedthe formation of the Delirium and Cognitive Impairment Community of Practice toensure a multidisciplinary approach to delirium screening assessment andprevention.108. Following implementation of the new policy, the gap in the rate of hospital-acquireddelirium at St Vincent’s Hospital significantly narrowed and clinical care improved. Asa result of audits completed, it has been demonstrated that screening for patients atrisk of delirium increased from 21% at baseline to 93% in December 2020. Thepercentage of patients who had a comprehensive assessment to determine thecause of their delirium increased from 62% at baseline to 92% in December 2020.The success of the plan was also reflected in the data from the New South WalesClinical Excellence Commission’s quality improvement data system.109. RN Peter Jones68 outlined the improvements at St Vincent’s Hospital with respect tothe training and accreditation of nurses in relation to CVADs. He explained that allregistered nurses working in areas where CVAD use was common were identifiedand required to have CVAD accreditation. In wards where CVAD use is less common,the training and competencies are recommended for clinical nurse specialists,clinical nurse educators, and team leaders.110. Mr Moulds’ case has provided an opportunity for lessons to be learned for thetreating practitioners and St Vincent’s Hospital. The significant changes that havetaken place at the Hospital are supported by rigorous audit compliance and67Tab 6568Tab 6620Findings in the Inquest into the death of Kelvin Mouldscontinuing education. In those circumstances, I do not propose to make anyrecommendations.Findings pursuant to section 81(1) of the Coroners Act 2009111. Kelvin Moulds died of hypoxic encephalopathy on 9 March 2016 at St Vincent’sHospital, Sydney, New South Wales, in circumstances arising from a cardiac arrestfollowing his self-removal of the central venous catheter five days before.Non-publication order112. Pursuant to section 74(1)(b) of the Coroners Act 2009, I order that any evidencetending to identify the street addresses, email addresses and phone numbers ofmembers of the Moulds family not be published.Carmel ForbesDeputy State CoronerNSW State Coroner’s Court, LidcombeDate: 16 April 2021