GRAFTON man John Gibson died because a central venous line was inserted into his carotid artery rather than his jugular vein while at Grafton Base Hospital.
The error caused medication to be infused into his artery, leading to Mr Gibson to suffer a brain injury that led to his death in Lismore Base Hospital on July 3, 2011.
A coronial inquest in Sydney heard Mr Gibson, was admitted to Grafton hospital on June 24, 2011 with a life-threatening medical condition exacerbated by long-term alcohol and tobacco addictions.
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He underwent emergency surgery where surgeon Dr Alison Duchow identified a twisted bowel, which was repaired.
A day later Mr Gibson began exhibiting symptoms of alcohol withdrawal, for which he was given doses of valium.
When he began to show further complications the next morning, an Emergency Medical Team was called to attend.
Dr Duchow and anesthetist Dr Alan Tyson determined Mr Gibson should be transferred to Lismore Base Hospital, and Dr Tyson decided to change Mr Gibson's medication and to insert a central line to provide an additional means of access to the vein should Mr Gibson need more medication.
Dr Tyson inserted the central line and checked on an x-ray that its tip was not likely to cause complications.
It was not until 36 hours later, when Mr Gibson was in intensive care at Lismore Hospital, that it was discovered the central line had been placed into his carotid artery rather than his jugular vein. The error was discovered by a nurse.
By that time a number of medications had been delivered by the central line.
A CT scan showed a right-sided brain infarction that the inquest heard was consistent with the damage expected as a consequence of fluids being conveyed via the carotid artery directly to the brain.
Lismore hospital staff determined the brain injury was catastrophic and Mr Gibson was given palliative care until his death.
Dr Tyson, who told the inquest he had been inserting central lines since 1983, said if a central line was placed into an artery blood would pulse out of it. He relied on the absence of pulsating blood, and the colour of the blood, to determine he was not in the artery. He did not conduct any other check.
Under examination, Dr Tyson conceded Mr Gibson's blood pressure may have been so low that there was no pulsation.
Deputy State Coroner Elaine Truscott said Dr Tyson at no stage attempted to distance himself from having placed the central line into the artery, accepting it was inadvertent.
She said, however, the line should have been checked by a means other than the presence or absence of pulsing blood.
Ms Truscott recommended Northern NSW Local Health District mandate practitioners confirm placement of central lines consistent with advice given Grafton Base Hospital in 2011 after Mr Gibson's death.