Failures left doctor dead from sepsis
A PSYCHOLOGIST who moved to Tasmania - after being professionally reprimanded for kissing an office junior in Townsville - later died in Launceston after hospital staff failed to transfer him for a likely case of septic shock, a coroner says.
Calvary St Vincent's hospital staff failed to take observations of Peter Golus, 65, every five minutes as directed in November 2017 after an "uneventful" kidney stone operation, Coroner Simon Cooper said in newly-released findings.
Instead, Mr Cooper said medical records showed his vital signs were not recorded for three-and-a-half hours after his blood pressure dropped to "dangerously low" levels.
According to Queensland Civil and Administrative Tribunal documents, the Psychologist Board of Australia reprimanded Dr Golus for unsatisfactory professional conduct after kissing a junior administrative officer in 2009, which she described as "gross" and having felt "violated".
Dr Golus, who had previously been disciplined by the Psychologists Board of Queensland over an inappropriate relationship with a patient, moved to Launceston in 2013 and worked in private practice before taking on a forensic neuropsychologist role two years later.
In his findings, Mr Cooper said the 65-year-old was in good health when he underwent surgery, with stable vital signs and declining pain relief afterwards.
But within an hour his temperature started to rise, Mr Cooper said, before he started vomiting into the night, complaining of abdominal pain.
Dr Golus was given morphine at 2.25am the next morning before his blood pressure dropped to a "dangerously low" level at 60/40 and his temperature decreased.
Mr Cooper said Dr Golus' doctor directed nursing staff to take observations every five minutes.
But as there was only one nurse working in the high-dependency ward caring for three patients, hospital staff made a decision to leave Dr Golus where he was, meaning they didn't have the ratios to take his observations every five minutes.
Mr Cooper said a statement from one registered nurse saying she was advised his blood pressure had improved at 2.45am "cannot be correct".
At 5.45am, Dr Golus woke up, reporting an eight-out-of-10 pain level, with his heart rate having increased and his blood pressure still dangerously low.
Dr Golus phone his son who came immediately, but reported by the time he arrived, his father could no longer speak or see properly.
At 6.45am, the morning shift co-ordinator reviewed his overnight history and decided to move Dr Golus to a high-dependency unit.
Mr Cooper said that decision came "belatedly".
Within two hours, Dr Golus was unresponsive, was transferred to Launceston General Hospital, and died about 10.15am.
An autopsy found the cause of death was escherichia coli urosepsis, a severe infection in the urinary tract.
The coroner's medical advisor said by 2am, Dr Golus had developed shock - likely septic shock - and should have been transferred to Launceston General Hospital at that time.