Queensland’s Health Ombudsman has today released the findings of his investigation into the death of Arkadiusz ‘Arthur’ Tumanis at Cairns Hospital’s mental health unit in 2015.

Arthur presented to the emergency department on two occasions in 24 hours. As no physical cause of Arthur’s pain could be identified and he had a history of presenting with physical symptoms when he was experiencing an acute change in his mental health, Arthur was admitted to the mental health unit.

Despite intervention aimed at reducing his agitation, Arthur continued to complain of significant pain. Two days after his admission, Arthur was found unresponsive near the nurses’ station and was not able to be resuscitated. Arthur’s death was found to be a result of peritonitis due to an undetected perforated ulcer.

The published report notes the investigation found a number of systemic issues contributed to Arthur’s unexpected death, and took into account the recommendations from a clinical incident analysis and any system and process issues that arose as a result.

Health Ombudsman Andrew Brown has made two recommendations to Cairns and Hinterland Hospital and Health Service (CHHHS) relating to future unexpected adverse outcomes experienced by CHHHS patients.

“The recommendations focus on improving communication surrounding all adverse health outcomes with the parties involved, and full and timely implementation of any recommendations arising from an ensuing clinical incident analysis,” Mr Brown said.

“We believe these recommendations will result in improvements at CHHHS to prevent the occurrence of similar adverse incidents in future.”

The OHO will continue to objectively monitor and work with CHHHS to ensure all recommendations are fully implemented and will conduct a further review in 12 months’ time.

“Through these findings and recommendations, I hope today to provide Arthur’s family with a sense of closure and I thank them for their patience through this protracted process.”

CHHHS has accepted the recommendations and, since 2015, has undertaken work to introduce a new clinical incident management framework and provide better quality of care to patients with a dual diagnosis, that is, patients with both a mental health impairment and a problem or disorder relating to substance abuse.

“There is increasing recognition of the impact an individual’s mental health can have on their physical health, and the importance of providing quality, holistic care to patients with dual diagnoses,” Mr Brown said.

“Arthur’s case highlights the need for health practitioners to treat all aspects of an individual’s health—including their physical health—throughout the course of their admission, and to be mindful of the potential for decision-making to be influenced by the knowledge of a dual diagnosis.”

The full investigation report is available on the OHO website at www.oho.qld.gov.au. Arthur Tumanis has been identified with the consent of his father, the complainant.

In addition to but separate from this investigation, the OHO has referred a number practitioners to the Australian Health Practitioner Regulation Agency as a result of the complaint.

—ENDS

Download the report

Media enquiries:

media@oho.qld.gov.au 0427 483 656