The following is an unedited transcript of the Coroner's verdict delivered on February 29, 2008 at the conclusion of an inquest into the death of Christopher Esfakis at Doctors Hospital in April 2002. The final wording of the ruling is expected to be available in the near future.
THE COURT:
At this point it is my responsibility to sum up and give you directions on the verdict or verdicts to be arrived at.
I should say -- okay, I have my directions which I'll read and it would be clear as to the procedure. All the evidence is now completed. Throughout this inquest, the law has been my area of responsibility, and I must now give I directions as to the law which applies in this case. These directions of the law must be followed.
There are cases in which the state of the evidence is such that it is possible that there could be, that there would be different views on the verdict as to the cause of death to be arrived at, and in those kinds of cases I would, after giving you legal directions, leave a number of verdicts that properly arise on the facts for you to decide on the appropriate verdict. To decide on the proper verdict in a case in which there is different advice, in those situations the jurors have the responsibility to decide on the proper verdict.
There are other cases, however, where if in my view as Coroner, the facts in evidence point in one direction, only point towards one verdict and no other, then I am bound to direct that you arrived at that verdict.
I have thought about their case and the more I did the summing up the more I came to the view that it is one such case that the appropriate verdict as to the cause of death; that is, how and after what manner Mr. Christopher Esfakis died, and for which I must direct that you arrive at, is as follows:
This case responds in one direction only. In those circumstances, I have a responsibility to direct you to that verdict. Christopher Esfakis died from natural causes with a substantial and significant contribution by neglect on the part of Doctors Hospital medical and nursing staff, in the management of his burn injuries. This neglect was twofold:
A.Gross failure in timely securing his airway resulting in the closure of his upper airway.
B. Gross error in the calculation of the deceased's fluid deficit resulting in over hydration.
The standard of proof is on a balance of probabilities -- it's not difficult to explain that. Just imagine a scale on a balance (indicating) just a balance of probability, but even if the higher standard was used -- that is for a reasonable doubt, you must be sure. Neglect, in my view, would still be proven, so compelling in my view is the evidence. The standard of proof is easily there.
The identity of the deceased, when and where he died, these are not in dispute, and will be entered on the verdict sheet. I'll now, for the record, explain how I arrived at my decision.
This verdict -- natural causes contributed to by neglect -- natural causes means that, as it says, the natural outcome of a certain disease and death, and therefore if left to occur on its own, that is death by natural causes. It is pretty self-explanatory. There is no human intervention. There is no other reason for death but the natural outcome of the disease or accident.
But the neglect is part of the verdict which I think needs to be explained. It is defined as gross failure to provide adequate nourishment or liquid or procure basic medical attention or shelter or warmth for someone who is in a dependent position, because of (in this case illness), and who cannot provide it for himself. Failure to provide medical attention for a dependent person whose physical condition is such as to show that he obviously needs it may amount to neglect. And on this definition, the opportunity for rendering care was not taken, and this failure caused death.
That is, there are opportunities that were not taken, and they caused death.
Neglect also applies to cases where medical care is not absent, but is given inappropriately, as a result of poor exercise of clinical judgement and errors in diagnosis or treatment.
Whatever the neglect, whether the result of absence of medical care or care given but improperly administered, such neglect is confined to areas of basic medical care.
That is, you are not dealing with a situation of complicated procedures that may require some degree of difficulty. Not that level of medical care, but basic medical care. Neglect is confined to that situation. It is purely fact-based and has nothing to do with the civil concept of liability and duty of care. We are not saying that doctors owed a duty of care to Esfakis, but on a purely factual basis was there neglect, if you find gross failure to provide medical treatment. If the neglect does not cause death then it can't be said to have contributed towards death.
So what the law says: There must be, in other words, a clear and direct causal connection between neglect and death. If neglect did not cause death or the patient would have died anyway, then there is no causal connection between the medical care given and death. The neglect need not be the only cause but it must, more than minimally, contribute to death.
So if there is some other cause that contributed toward death that
would not prevent you from finding neglect, if neglect also made a
contribution, so there can be an argument, well there are other causes
so it can’t be neglect; neglect can be one of the causes. And once it is more than minimally contributed towards death,
once it makes a material contribution, then the connection is established.
The test really is: But for errors in the medical care given, death would not have occurred. That is the test.
But for errors in the medical care given death will not have occurred. So that is the law on neglect.
The facts: About 20 witnesses gave evidence. At 1:00 a.m. on the morning of Saturday, the 20th of April, 2002, Christopher Esfakis was admitted to A&E of Doctor's Hospital, suffering from burn injuries he stained about 30 to 40 minutes earlier. He walked into A&E without needing any physical assistance. His injuries were assessed as at 25 per cent body surface area, mostly to the chest, arms and face, with his hands - palms - getting the worst of it, third degree burns; and his face, neck and chest, first and second degree burns.
He was further assessed as having sustained an inhalation injury and treatment program put in place by Dr. Iferenta, his primary care physician. His chances of survival and more or less full recovery, the entire medical evidence was in agreement. His chances of success was put at over 90 percent, more precisely in the range of 95 to 97 per cent, according to one doctor.
Doctor Neymour, the other physician of significance, in relation to the drawing up a treatment program, agreed with Dr. Iferenta’s assessment although, as I shall deal with later, there were important differences in the critical area of timing in relation to securing the deceased's airway by intubation, which both physicians acknowledged, what was to be done Dr. Neymour said no; Dr. Iferenta said yes, but later -- was necessary.
At 7:00 p.m. on 22nd of April, 2002, or less than 72 hours after his admission - 66 hours to be exact --Christopher Esfakis was dead. The pathologist put the cause of death as a) Cardio respiratory arrest, acute pulmonary congestion and odema; b) airway obstruction due to inhalation injury 2a)burns b) pending reports from Forensic Science Laboratory. 2b) can be ignored and nothing of consequence came out of the forensic examination.
This is saying death is cardio respiratory arrest, airway obstruction. Those are the two main points, and burns as the underlying third cause of death.
Of significance was his body weight at the time of death, 190 pounds. Upon admission on April 20th Christopher Esfakis weighed 130 pounds and was described as "slim”.
The question at this inquest, what it has to determine is: What was the cause of death? To put it in a literary manner, "How did death with a less than 10 percent chance of success defeat the life of Christopher Esfakis, whose chances of survival were assessed at over 90 percent". The answer to that question will determine the verdicts to be left to the jurors, or the verdict to which they must, because of the evidence, be directed to arrive at and to direct you to arrive at a certain verdict.
In my view, the evidence of all the physicians and nurses given was given in an honest, forthright and objective manner. There were no attempts to embellish or mislead. In my view, the evidence taken in its totality is a fair representation of the facts concerning the treatment/care that Christopher Esfakis received.
The deceased was correctly diagnosed as suffering from an inhalation injury. In order to preserve and not fitter away the over 90 percent chance of survival, this required at least two things: Again, there is a consensus of medical evidence given in the inquest on the requirements necessary to make good Christopher Esfakis' chances of survival.
1. Timely; which meant immediately security of the airway. Timely meaning, if necessary, immediate securing of the airway by intubation.
2. Adequate fluid administration and,
3. Thirdly, but perhaps, in this case, not so critical, transfer to a burn unit. All three are readily available in the Bahamas.
Dr. Neymour says he stated to Dr. Iferanta, in what seems to have been a kind of conferring with Mrs. Esfakis, the deceased's wife, in the IMCU corridors, his preference for the immediate securing of Christopher Esfakis’ airway, by intubation and equally immediate transfer to ICU, where Christopher Esfakis would obviously be expected to have close monitoring. The recommendations by Dr. Neymour for immediate intubation is not in his doctor's notes, but Dr. Iferenta does not dispute that Dr. Neymour recommended immediate intubation and immediate transfer to ICU.
However, the two have different approaches. In fact, Dr. Iferenta adopted a somewhat different approach. He says he would watch and see what happen; and also to keep Christopher Esfakis in the IMCU. In effect, to postpone intubation and not adopt as close a monitoring as Dr. Neymour proposed.
As the primary care physician, his recommendation determined the treatment program of a watch and see approach, essentially a monitoring approach; example, monitoring the airway for signs of closure, and if necessary, intervene. That is what I take it he meant. It wasn't intended to be a passive watch and see.
The evidence in relation to the calculation of the fluid deficit is somewhat different. Again, the medical evidence is not in dispute. There is a formula for the calculation of the fluid deficit: 2 to 4 liters times the 7 percentage burn, times the body weight. This is basic medicine.
In Christopher Esfakis' case, it is agreed on the evidence that this formula reads 2 to 4 liters times 25 percent times 60k. Or 2.7 to 3 liters. This would result in Christopher Esfakis passing urine at 30 to 50cc per hour. This was the figure, or at least the range that Dr. Neymour says in his evidence that he arrived at and expected would be used.
Dr. 1ferenta's calculation, which he admits was in error, came to 12 liters with infusions of 400 to 500cc per hour. The total fluid infusion Christopher Esfakis should have received -- and again this is not in dispute -- was in the region of 6 to 9 liters within the first 24 hours.
Instead, according to the nursing notes Christopher Esfakis received 28 liters in the first 24 hours. Dr. Lutherman based on his study of the doctors and nursing notes, in his evidence, states "His urine output at this stage is far too high, implying an infusion of far too much fluid". As a result, Christopher Esfakis consistently over the three days passed abnormally high levels of urine output, sometimes up to 500cc per hour. Dr. Garners' summary of these notes suggests much more over short periods of time.
To quote from Dr. Garners' summary of the: hospital records "There is one input/output chart which is not dated that seems to indicate hourly; urine outputs of up to 1,380cc per hour. This is; the same chart that has an input of 28,237 per 24 hours and an output of 10,980 per 24 hours; example, an average of 457cc per hour”
For reasons that are still not entirely clear to me, the fluid infusion given to Christopher Esfakis was, from a strictly factual, quantitative and no legal standpoint, grossly and at times, massively in excess of the figure generated by the accepted formula. Christopher Esfakis was in fact given, and given consistently, fluid infusion ranging from 250 to 500 cc per hour and at one stage on Sunday at 12:00, some 5 hours before he died, Dr. Iferenta ordered an increase to 1000cc per hour. On Sunday, orders were given at one point to decrease the infusion to 500cc, but at that level it was still too high and a serious danger to Christopher Esfakis' chances of survival which at that time had become very slim.
Dr. Iferenta admits there was a miscalculation in the fluid infusion, but what remains a mystery, is not the error but its continuing magnitude and in the context where his colleague got it very right, so to speak, how did Dr. Iferenta get it so very wrong? An indication of just how gross was this error can be gauged by the body weight of Christopher Esfakis on admission 135 pounds and at death 190 pounds equals 55 to 60 pounds gain in 66 hours. It is not in dispute that the excess fluid infusion caused this weight gain.
There is again a medical consensus in the evidence that such a significant over infusion would put serious strain on his cardiovascular system and hasten the swelling and expedite the closure of Christopher Esfakis' upper airway by the accumulation of fluid in the tissues of the upper larynx, also elsewhere in the body; for example, in the lungs, both of which eventually suffered “White out” by the Sunday, thereby seriously compromising gas oxygen/co2 exchange in the lungs. The pathologists lists this Cardio respiratory arrest and acute pulmonary congestion and oedema as the number one cause of death, and his finds are supported by the evidence of Dr. Garner, Dr. Lutherman and Dr. Neymour.
Again, what I find inexplicable is Dr. Iferenta's account that having determined this level of infusion at 9:00a.m, by 5:00p.m. he had no reason to reduce it because he had no information concerning Christopher Esfakis' urine output. At a minimum, such a state of information or lack of it should have prompted an investigation by Dr. Iferenta. If no urine was being passed, where did all that infusion go? And, if urine was being passed, how much? No such investigation was done. Instead, Christopher Esfakis continued to receive , significant over infusion of fluids.
To admit, at 5:00p.m, ignorance and further lack of curiosity on such a vitally important area as fluid infusion in a burn patient is indeed quite troubling and indicates 2 insufficiently close monitoring in fact no meaningful monitoring of his urine output. Dr. Iferenta seem to have relied on the readings of the blood count to monitor hydration; but urine output is accepted as a more reliable indicator.
The facts concerning Dr. Iferenta's "watch and see" monitoring approach are not in dispute, in relation to Christopher Esfakis' airway from 5:40 p.m. on April 20th and onwards, Christopher Esfakis began to complain about a feeling of tightness in his throat. This is the earliest recorded time in the nursing notes, but it is clear from these same notes that Christopher Esfakis had complained earlier that afternoon, before 5:40p.m, to Dr Iferenta about the tightness in his throat. From 5:40p.m. Christopher Esfakis more or less consistently complains of this tightness. The nursing notes at 5:40 p.m. in relation to consultations with Dr. Iferenta state that "patient symptoms are related to bulky dressings".
Dr. Iferenta says in evidence that this was not his opinion, his view or instruction. Somehow this was the nurses' interpretation or a view the nurse somehow came to record as he himself had examined the dressings and found them to be loose and non-constructive.
The question then was: What was causing this feeling of constriction
and feeling of tightness? Christopher Esfakis was an asthma sufferer,
but there is no evidence that Dr. Iferenta determined that the
constriction was due to an asthma attack. What therefore was causing
this constriction? From his evidence, Dr.
Iferenta does not investigate and it apparently never occurred to him
that Christopher Esfakis' airway was, as would be catastrophically
evident some 10 hours later, closing down.
How this latter possibility in fact probability given the state of
medical science could have escape Dr. Iferenta's attention, or failed
to become the focus of attention, or failed to become the focus of
attention and investigation remains a mystery. It can’t be reasonably
said to be a judgement call because, given all the data
available to Dr. Iferenta, at this point, at 5:40p.m. there is really
no room for legitimate differences in assessment and deciding on
differing treatment options. Maybe earlier at 9:00a.m. Certainly not at
5:40p.m.
One known consequence of inhalation injury and one which medical personnel are always on the alert for is airway closure.
This knowledge in the medical sciences is a sort of ABC in the care of
patients suffering from inhalation injuries. Dr. Lutherman constantly
underlines the need for such alertness/vigilance in his evidence.
Dr. Iferenta ought to have known this risk of airway closure and be
alert to the likelihood of its occurrence. He said that at 9:00a.m.
that morning that Christopher Esfakis suffered from inhalation injury.
His colleague at that time, I recommended immediate intubation. He says
postpone. Sometime in the afternoon and before 5:40p.m. Christopher
Esfakis complains of constriction and difficulty to breathe. Dr.
Iferenta, himself, personally determines that the feeling of
constriction is not caused by tight bandages because he, himself,
tested the bandages and found them not to be
constrictive.
What then prevented him from taking a small deductive step for airway closure? What prevented that small step to deduce airway closure? That is the first thing.
So at 5:00pm the program of “watch and see” continues, the interference being, if something amiss is seen then appropriate intervention would be done.
But no intervention outside of the initial treatment program takes place and the routine of watching and seeing and following the initial treatment continues essentially unchanged and unamended. In my view, the period from 5:00p.m. onwards represents a rapidly closing window of opportunity to secure Christopher Esfakis airway. Christopher Esfakis's airway is not visualized and in a manner of speaking it is "business as usual" on the basis of the initial treatment program. Dr. Iferenta may have been reasonable in not intubating at 9:00a.m. on the 20th, but not to even seriously consider intubation at 5:40 p.m., to meaningfully weigh its necessity, I think, indicates a gross failure in Christopher Esfakis' treatment.
So, at 9:00a.m. on the 20th it is, reasonable not to intubate.
At 5:40 p.m. when there are clear signs that point to difficulties with the upper airway, at that point there is no meaningful assessment, in evidence, to intubate I think that indicates gross failure.
This assessment of the quality of care administered by Dr. Iferenta is not the result of hindsight. Anybody could say from hindsight, 20/20 vision, the extremely grave dangers of inhalation injury is basic knowledge in the medical sciences. It is not unreasonable to expect Dr. Iferenta to I have possessed this knowledge and therefore to have placed the securing of Christopher Esfakis’ airway, as an immediate and pressing priority in his mind.
What I am saying: At that point, 5:40, given his basic knowledge, there must have been an appearance in his mind; and they expect a doctor would have known this, and therefore this would have been in the forefront of his mind.
Dr. Iferenta says, his experience with other burn patients is that he did not intubate and they survived. It would have been more reasonable for Dr. Iferenta to base Christopher Esfakis' treatment on the requirements of medical science than on the survival rate of the burn patients he had managed in the past.
Further, this was not a complicated medical case where there were legitimate differences over optimal treatment options each having its own distinct dangers. Here there was no debate or agonizing over treatment options. It was a basic and straightforward issue of the timely securing of Christopher Esfakis's airway which if done in a timely manner is a relatively uncomplicated and simple nonlife-threatening if somewhat uncomfortable procedure.
At least one doctor thought that Christopher Esfakis' constriction was due to tight bandages around the throat and recommended at 8:00p.m - - three hours after Dr. Iferenta determined that tight bandages was not the problem. He recommended loosening them. This indicated some confusion -- conflict had now crept into the management of Christopher Esfakis' burn injuries.
At 5:40 pm Dr. Iferentia said this not a tight bandage. At 8:00pm, another doctor said tight bandage, loosen them. What exactly is it? Tight bandage or not tight bandage? So, there is inconsistency in the management of Christopher Esfakis -- although, to be fair, that doctor was not the person responsible, but insofar as he gave some recommendation that had to do with tight bandage when Dr. Iferenta said it is not tight bandage indicated there is some confusion. They are saying different things.
Between 9:00 to 10:30p.m on the 20th, Christopher Esfakis has
significant breathing difficulties at one time at 9:00p.m. described as
"acute" . The nurses unsuccessfully tried to page Dr. Iferenta. He offers in evidence what I believe is a credible explanation for the
failure to get him by pager. He does not have a pager. But that,
in my view is beside the point. Basic care for a I patient like
Christopher Esfakis required much closer monitoring. Dr. Iferenta
should have called the hospital to check upon Christopher Esfakis. Not so doing was a significant failure. And what is one to make of the
nurses urgently paging Dr. Iferenta, who in turn says, he has no pager?
In my view, neglect is cumulative result of all these errors and if
death results, in no way could it be said to have been due to natural
cases.
The period between 10:30p.m. on the 20th and 3:45a.m. on the 21st when Christopher Esfakis is in moderate cardiopulmonary distress is cyanotic and his airway now closed is not one of steady decline-according to the nursing notes. For some reason, not fully explained between 12:00am and 2:00a.m. on the morning of the 21st Christopher Esfakis is resting comfortably with not problems. This respite in the context of what happened immediately before 12:00a.m. and after 3:00 a.m. somewhat puzzling.
By 3:00a.m. on the 21st, Christopher Esfakis' breathing difficulties return, this time in a directly life-threatening way.
In the view of Dr. Lutherman, The physicians response at 3:00a.m. on the 21st, to monitor saturation (oxygen) showed a lack of understanding of the pathophysiology involved. These patients will maintain normal (oxygen) saturation until obstruction. The only way to monitor the development of upper airway problem is by direct visualization of the upper airway and timely stenting the upper airway and larynx with an endotracheal tube. This was obviously not done with I catastrophic results.
At 3:00a.m. high, normal oxygen level, and the doctor said, "Well, it is okay." But the evidence, the signs showed that they maintained a high levels until closure. So the high level could I be deceptive, if you believe that means he was okay. You can have a high level and not be okay because it is closing down. But, the body does not show the lack of oxygenation until the last minute, so to speak.
The opinion of an expert should not be accepted without question, but should only be rejected if there is very good reason to do so. Because he is an expert does not mean that you automatically accept his evidence. You need to look at it and don't automatically, without question, accept the view of an expert. However, I will rely on and accept this view of Dr. Lutherman. What it suggests is that at 3:00a.m. when Christopher Esfakis was still conscious, not cyanotic, not yet in any state of cardiopulmonary distress, there could still and should have been an intervention, along the lines he indicated. This is not to say I that such intervention would have saved his life, but even at that late stage the opportunity for rendering meaningful care had not completely gone.
Remember, he is still conscious. He is not turning blue. He is still conscious. He is in a better position in that he is not in a state of cardiopulmonary distress.
Instead there was a further delay of effective intervention for another 45 minutes perhaps prompted in part by Dr. Antonio's misunderstanding of normal oxygen saturation readings as an indication that "the patient should be okay", when in fact Christopher Esfakis' airway was undoubtedly closing down as this would be made tragically clear 45 minutes later.
I say "perhaps" because the evidence is, and I believe its true that Dr Antonio was busy in A&E at that time but her response clearly indicates a misunderstanding as characterized above by Dr. Lutherman. The fact is at that critical juncture no one at Doctors picked up what was fairly easy to pickup; example, the closing down of Christopher Esfakis’ airway. Alongside this failure to secure Christopher Esfakis' airway and aggravating the swelling that ultimately led to that closure was the significant over infusion of fluids.
Dr. Lutherman states, "The impact of this, far too much fluid, would be to overload the patients circulation exaggerating the swelling that was occurring in his upper airway be, and increasing the fluid collecting in his lungs."
The attempts to intubate after airway closure were indeed tragic. Tragic because it was a completely avoidable situation in an area of basic medical care and further since there had been persistent and clear warning signals, the failure of the attempts dramatized consequences of waiting until it was too late to intubate.
At this time of the failed intubation efforts, Christopher Esfakis it should be noted was I cyanotic, blue, from hypoxia or lack of oxygen and in the words of the nursing notes, 'in moderate cardiopulmonary distress."
Natural consequences of his burn injuries did not get him in that critical state where the tracheotomy, performed in good time, failed to save his life.
There is no doubt that failure to intubate completed with the over infusion were the material and significant causes and underlying conditions that led to Christopher Esfakis' death. Together they closed down his airway, making him cyanotic, exposing him to the risk of brain damage and putting serious strain on his cardiovascular system. They were on the medical evidence the direct triggers for the ARDS (acute respiratory distress syndrome) that Christopher Esfakis developed after admission to ICU and that led to the fatal white out of both of his lungs.
Nothing of significance occurs after his admission to ICU at 4:00a.m. on the 21st until his death at 7;10 p.m. on the 22nd, apart from the continuing over hydration. Nothing to suggest errors in his treatment as all the medical personnel can do at the stage is to keep him alive and hoping that by the strength of his inner resources he will pull himself out of the crisis.
This tragic sequel of decline leading ultimately to death was due to the neglect in the special sense in which this term is used in Coroners proceedings. A verdict of natural cases without more or accident would be completely unjustified, given the state of the evidence.
It is no exaggeration to say that Christopher Esfakis's 90 percent chance of survival was frittered away by the cumulative errors of neglect in his medical care. That is what gave the natural consequences of his inhalation injury the chance to run their natural course to his death.
Jurors, I now formally direct that you arrive at the verdict I have stated above. The interested parties may apply for judicial review of my directions to the jury.
I want to thank the jurors for their patience and forbearance, and the attorneys of the interested parties, and the marshal for the thoroughness of this investigation.
Okay, those are the reasons that I have felt necessary to state, come to the conclusion that the only verdict 'on the evidence was natural causes with a substantive contribution of neglect. What it means, jury, is that you will not deliberate, because there is nothing to deliberate.
left you a number of verdicts, which would put you in a dilemma, in my view, because the evidence really points in one direction only. One could not say natural causes, given the state of the medical treatment. Natural causes would simply not be a verdict that one could arrive at. I would not want to put a perverse verdict. If one said he died of natural causes, given the state of the evidence, given the error made when the signals and warnings were pretty clear that, in my view, the fluid infusion error should have been identified but he never picked up, it continues right through, down to the very last - down to, you know, it is never corrected. So, I believe that fairly stated this verdict is the only possible verdict to arrive at, based on the evidence.
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