A CORONIAL inquest has found the 2016 death of Gunnedah father Alex Costello was due to natural causes.
Coroner Les Mabbutt handed down his findings regarding the death of the popular rugby player in the Gunnedah Coroner’s Court on Friday.
Mr Mabbutt told the court he examined several factors regarding the 37-year-old’s death, including whether Mr Costello should have been transferred to Tamworth, after being admitted to Gunnedah hospital.
“I find that Mr Costello should have been transferred from Gunnedah to Tamworth,” Mr Mabbutt said.
“However, taking into account the times indicated above are all optimal and when Alex collapsed at Gunnedah Hospital, I find on the balance of probabilities it is unlikely Alex would have survived.
“However, due to a failure to properly diagnose Alex’s condition, Alex was not given the chance of surgery.
“I find that Mr Costello’s death was not preventable.”
Mr Mabbutt also found the “Chest Pain Pathway” (CPP) diagnosis method “was not properly utilised” by hospital staff on the night of Mr Costello’s death.
“I find several factors to be inadequate,” he said.
“Notes taken by [the doctor] and other staff at the hospital on the night of Mr Costello’s death were insufficient and not properly detailed.
“I find Alex’s wife, Emma,and sister-in-law, Michelle Wicks, to be very credible witnesses and I find that they informed staff regarding Alex’s family history, but did not know the term, aorta.
“I find that the nursing and doctor staff did not at the time, have proper induction into how to use the CPP.”
The court heard of several recommendations to be brought forward as a result of Mr Costello’s death.
“Alex’s case has highlighted the importance of the proper clinical use of the CPP in accordance with NSW Health Policy at sites that do not have emergency or coronary specialists available,” Mr Mabbutt said.
“I make the following recommendation to the Hunter New England Local Health District: that all nursing and medical staff who perform duties at Gunnedah Hospital Emergency Department are reminded as part of their induction and ongoing training of the importance of clinical use of the NSW Health CPP.
“In addition, all staff are to receive training regarding their specific roles and responsibilities in the use of the CPP.
“Audits are to be performed at Gunnedah Hospital to ensure compliance with this recommendation.”
Mr Mabbutt thanked the court for co-operating throughout the inquest.
“Alex’s tragic death has impacted enormously on Emma, their three young children and all of their families.
“Alex was well regarded and respected in Gunnedah, a community where Alex and Emma had decided to settle and bring up their young children together.
“I express my sincere condolences to Alex’s family for their loss and thank them for their co-operation during this inquest.”
Mr Costello died suddenly on April 9 2016 after suffering chest pains.
The court heard prior to his death Mr Costello had been taken to Gunnedah hospital and had several tests but staff didn’t identify a heart problem.
He was transferred to the general ward, collapsed in the shower and could not be revived.