00:01When Leo Barraclough went to Caboolture Hospital suffering back pain, his family never dreamed
00:08his condition could be life-threatening.
00:10I really just thought that he had pneumonia or sepsis or something and that they were
00:16going to treat it.
00:17But the next morning they received shocking news.
00:21Leo had died.
00:22I was just devastated.
00:26The hospital ticked a box saying the pensioner's case did not need to be reported to the coroner
00:32who can investigate deaths involving poor health care.
00:36Instead, it listed Leo's death as not unexpected, caused by pneumonia and a pre-existing condition.
00:44That was a shock, so I just felt that there were so many things that did not add up.
00:50They were right to be concerned.
00:52A health service review document reveals multiple issues, including that he waited 12 hours for
00:59antibiotics, that he had received significantly more morphine than the recommended starting
01:04dose for a person his age, his observations were not taken and crucial blood test results
01:10were not passed on to doctors.
01:12I'm horrified that elderly people can be left in that state for that long without any treatment,
01:20observations or action taking part.
01:23The review did not find that the treatment caused Mr Barraclough's death, but highlighted
01:29numerous missed opportunities with his care.
01:31The ABC put more than 30 questions to Caboolture Hospital, asking why the many issues with
01:38Mr Barraclough's care did not result in his death being reported to the coroner.
01:43Four days after receiving the questions, Metro North Health Service issued a statement saying
01:48the death was now being reported to the coroner out of an abundance of caution.
01:52The coroner's recommendations are vital for the healthcare system. The recommendations that
01:57they provide systems help improve safety and quality in practice for healthcare professionals
02:04to mitigate risks for patients in the future.
02:07Metro North Health says clinical decisions are based on patient symptoms and known medical history,
02:13and all unexpected deaths are reviewed.
02:16The initial review identified improvements around documentation which had been implemented,
02:22and Caboolture Hospital held an open disclosure meeting with the family.
02:27The Health Minister has declined to comment given the case is now before the coroner.
