An elderly man was “left untreated to die in pain” and health services were more intent on defending their actions than analysing the facts, a damning coronial inquest into the death of two men in Darwin has revealed. Henry Wilson, 77, died from sepsis on September 19, 2016 — but despite that, Top End Health Service never reported his case to the coroner. Rather, the case was taken on as a “discretionary” inquest — meaning it was not legally required — following the service’s “poor response” to an expert report, which found there were delays in instituting treatment. On September 18, Mr Wilson was diagnosed with peritonitis during treatment for stage 4 colorectal cancer. Coroner Greg Cavanagh found Mr Wilson “waited in pain and feeling that his body was shutting down another 24 hours until the conversation was had with him about further procedures”. “There seemed however to be a lack of urgency in making a diagnosis,” he wrote. “It took Mr Wilson’s daughter demanding something be done before scans were ordered.” Mr Wilson died one day later from sepsis. The most junior doctor on the team, an intern, was asked to break the news to his family. The coroner found Mr Wilson’s death identified a number of issues, including poor communication with the family, poor communication between doctors, poor note taking, inadequate treatment of a dying man and failure to report the death to the coroner. “The communication issues were denied by the institution and in effect the deceased was blamed. “The Top End Health Service seemed more intent on defending its actions than critically analysing the facts.” NT Health chief executive Catherine Stoddart said the department would examine the recommendations and respond “in due time”.
