Thursday, May 17, 2018
This Made Me Wonder Just What Was Happening With The “Bonfire Of The Faxes”?
This appeared last week:
10 May 2018 — 6:08pm
Mettaloka Halwala was alone in a hotel room near Shepparton when he was found dead from complications that arose from his chemotherapy treatment of Hodgkin’s lymphoma.
Hotel staff opened the door of his room on the morning of November 17, 2015 to find the 58-year-old father of two deceased in his bed, fully clothed in jeans and a shirt, a lit torch beside him.
Now, a Victorian coroner has found Mr Halwala's lonely death could have been prevented had he not been let down by a series of systematic failures by the medical profession.
Four days before Mr Halwala's death, a scan conducted at the Austin Hospital showed signs of potentially fatal lung toxicity linked to his cancer treatment.
But a fax with the results of his scan was sent to the wrong number, Coroner Rosemary Carlin found.
This, combined with other "shortfalls in his medical management", meant neither Mr Halwala nor his haematologist Dr Robin Filshie at St Vincent's Hospital Melbourne was made aware of the results before a further fatal dose of same drug associated with the lung toxicity was administered.
While no one acknowledged responsibility for the communication failure, Ms Carlin found there had been "inadequate medical management" at the hands of both Dr Filshie and the physician responsible for sending the report, Associate Professor Sze Ting Lee.
"I cannot be certain that Mr Halwala would have survived even with optimal treatment but he may have," she wrote.
"The shortfalls in his medical management deprived him not only of his chance of survival but also of the opportunity to have a more comfortable death surrounded by loved ones."
In the months leading up to his death, Mr Halwala, affectionaly known as Mal, was living in a hotel in Tatura, a small town in the Goulburn Valley, due to his work as a civil engineer, while his family lived back in New Zealand.
Lots more here:
Now this is a sad story but really the specialist who ordered the scan and did not follow up is the one who should receive the most opprobrium.
That said the fax replacement program seems to have ground to a halt and I understand there are three contending views of the future slowing things down. Roughly there are those who want to finalise HL7 2.4, the pragmatists and the FHIR enthusiasts who want to move more quickly to the probable future.
Maybe we could have some leadership from the ADHA and move on, or is that too much to ask. It’s been almost two years now! That said my little Brother Multifunction (fax) has been a godsend in getting all my results during my recent travails! The fax sure is not dead yet…..
Posted by Dr David G More MB PhD at Thursday, May 17, 2018