Adam Fitzpatrick survived horror crash only to die in Sydney hospital blunder

Sadye Matula

Normal text sizeLarger text sizeVery large text size Adam Fitzpatrick was meant to be one of the lucky ones. After he was pulled from the wreckage of a car crash in the NSW Riverina region last year, plastic surgeons masterfully pieced together the shattered fragments of his face “like a […]

Adam Fitzpatrick was meant to be one of the lucky ones. After he was pulled from the wreckage of a car crash in the NSW Riverina region last year, plastic surgeons masterfully pieced together the shattered fragments of his face “like a jigsaw”.

Adam, an exuberant 20-year-old with a quick wit and big dreams, would lose an eye but otherwise fully recover, his family was told.

The good news meant the chance to trade hospital cafeteria meals for a family lunch out for Adam’s mother Philippa Fitzpatrick, who had kept a two-week vigil at her son’s bedside.

But as they walked out the doors of Sydney’s St George Hospital, the family was oblivious to the horror about to unfold behind them.

Adam’s life was ripped away by a series of cascading and catastrophic errors in the intensive care unit of one of NSW’s leading trauma hospitals.

A joint investigation by The Sydney Morning Herald and A Current Affair reveals that when Adam’s breathing tube became dislodged, doctors failed to recognise the problem, were unable to fix it and decided against calling for the help of a specialist who could have replaced the tube in minutes and saved Adam’s life.

“It’s basically a life sentence for all of us but what we’ve lost is nothing compared to what Adam’s lost,” Ms Fitzpatrick says.

“You killed my son. A beautiful boy with his whole life ahead of him, five days before his 21st birthday.”

While the staff floundered, Adam was starved of oxygen for 40 minutes, leaving him brain-dead.

The Fitzpatrick family alleges hospital staff went into damage control and attempted to cover up what happened. They were told Adam’s death was unavoidable as the result of a blocked tracheostomy tube, and he received the best care possible.

Adam Fitzpatrick with girlfriend Lucinda Eddy.

The family alleges they were subjected to intimidation and bullying after challenging the hospital, while medical records were withheld before being destroyed.

The Fitzpatricks were ultimately vindicated when the hospital’s own investigation found Adam’s death was caused by a delay in recognising the tracheostomy tube was dislodged and replacing it.

“There was an ineffective emergency response due to deficiencies in co-ordination, equipment, training and leadership which led to patient death,” the report, known as a root cause analysis, says.

The report notes the “inadequate response” to Adam’s unstable airway in the week before his death due to failures in “care co-ordination, handover and tracheostomy management”.

The events raise broader questions around whether enough is done in Australian hospitals to prevent catastrophic incidents involving tracheostomies and whether preventable deaths are covered up due to a lack of accountability.

The Fitzpatricks feel they would never have found out the truth if not for the family’s medical background. Adam’s mum, Philippa Fitzpatrick, is a veterinarian, and Adam’s sisters Amanda and Emma are a paramedic and a lawyer respectively.

Philippa, Peter, Adam, Emma and Amanda Fitzpatrick in an undated image.

Philippa, Peter, Adam, Emma and Amanda Fitzpatrick in an undated image.

Intelligent and ambitious

When Adam arrived back in his home town of Jugiong, about 120 kilometres north-west of Canberra, between university semesters, locals usually heard him before they saw him.

He would belt out country tunes as he drove down the main street of the historic town with a population of 200.

Adam’s passion was his new ute and parts continued arriving in the mail for months after he died.

His home base was a hobby farm on the banks of the Murrumbidgee River, where Adam would mercilessly tease his older sisters and parents, Philippa and Peter.

“He was probably the most intelligent person I know with an astonishingly quick sense of humour,” Emma recalled. “Most of the jokes were at my expense.”

Adam was ambitious, fast-tracking his study so he could work full-time for Local Land Services, a government agency in Hay. Adam planned to buy a block of land there and settle down with his girlfriend, Lucinda Eddy.

Adam Fitzpatrick with his parents Philippa and Peter. The Fitzpatricks feel they would never have found out the truth about Adam’s death if it was not for the family’s medical background.

Adam Fitzpatrick with his parents Philippa and Peter. The Fitzpatricks feel they would never have found out the truth about Adam’s death if it was not for the family’s medical background.

As workers arrived at a Hay truck yard on the morning of August 8, 2020, they discovered a ute crumpled underneath one of the trucks, where Adam had been trapped for about seven hours after a crash the night before.

Due to treacherous conditions, Adam could not be airlifted to Canberra and was diverted to St George Hospital.

The Fitzpatricks were relieved Adam ended up in the South Eastern Sydney Local Health District’s flagship hospital, which carries a high load of trauma patients from across NSW.

Adam was admitted to the ICU with severe head and facial injuries, and it was decided the bulk of surgery would be delayed two weeks while the swelling subsided.

A tracheostomy tube was inserted through Adam’s neck, connected to a ventilator that pumped oxygen into his lungs.

Adam Fitzpatrick was ambitious and had planned to buy a block of land to settle down with his girlfriend.

Adam Fitzpatrick was ambitious and had planned to buy a block of land to settle down with his girlfriend.

Adam’s mother Philippa was the only family member allowed into the ICU due to COVID-19 restrictions. She would reassure Adam when he woke, scared and disoriented.

She was the only person in the room when Adam tossed and turned and his tracheostomy tube broke free from the ventilator.

“Alarms were going off, but nobody came for quite some time and I had to reconnect the ventilator tubes myself,” Ms Fitzpatrick said.

“I kept thinking, why isn’t someone coming? If I had not been present on this day Adam could have died.”

The root cause analysis later found Adam was meant to have one-on-one nursing care, but it wasn’t provided because his nurse was attending a training session.

No formal handover took place notifying the other nurse on duty she would temporarily have to supervise Adam. The near-miss wasn’t logged until after Adam’s death, the report found.

‘It was almost like we were questioning God’

After the surgery, the Fitzpatricks were relieved to see their son “looking like Adam again”.

Adam was returned to intensive care, with plans to allow the sedation to wear off gradually. His tracheostomy appeared “secure and intact”.

However, the next morning Philippa felt uneasy because the tube appeared to be protruding at a strange angle.

She raised this with a nurse, who waved off her concerns. Ms Fitzpatrick had to vacate the room while a physiotherapist attended and alerted a nurse and a doctor as she was leaving.

The doctor was reassuring, Ms Fitzpatrick recalled.

“She said, worst-case scenario, if the tube comes out we’re all trained in replacing the tubes.”

While the family was at lunch, a nurse noticed Adam was struggling with mucus build-up and strong fits of coughing, according to the analysis.

After Adam started making gurgling noises his ventilator’s alarm activated, with doctors and nurses rushing in.

Despite the malfunctioning tracheostomy, Adam was breathing spontaneously on his own and levels of oxygen in his blood were normal.

After the facial surgery, the Fitzpatricks were relieved to see their son “looking like Adam again”. But the worst was to come.

After the facial surgery, the Fitzpatricks were relieved to see their son “looking like Adam again”. But the worst was to come.

However, doctors administered a drug that paralysed Adam’s muscles so a bronchoscope – a camera allowing doctors to see inside the airways – could be passed down the tracheostomy tube to check for blockages.

The analysis found that if the drug had not been administered, there was a possibility Adam could have maintained adequate oxygen levels on his own.

After the bronchoscopy, Adam’s condition deteriorated and he went into cardiac arrest.

CPR was commenced and doctors tried a variety of methods to restore his airways, but none were successful.

It was only when the ear nose and throat (ENT) medical officer arrived that it was found the tracheostomy tube was dislodged and in the pretracheal space.

The officer immediately placed the tube back into the correct position.

But scans three days later confirmed Adam had suffered catastrophic brain injuries from oxygen deprivation and he was declared dead.

The family returned from lunch to find a huddle of doctors around Adam in the ICU.

Philippa and Peter Fitzpatrick with their daughters Emma (on left) and Amanda, and Adam’s girlfriend Lucinda Eddy (right) in Jugiong.

Philippa and Peter Fitzpatrick with their daughters Emma (on left) and Amanda, and Adam’s girlfriend Lucinda Eddy (right) in Jugiong.Credit:Dominic Lorrimer

“We stood there for an uncomfortable amount of time with no one saying one single word to us,” Amanda recalled.

The family allege they were told the tracheostomy tube had become blocked, Adam had been without oxygen and his condition was “not good”.

It was left to Philippa and Amanda, with their medical backgrounds, to tell other family that Adam was likely to die.

During meetings that followed, the family allege facts kept changing to explain inconsistencies and staff were “aggressive and threatening” when challenged.

“It was almost like we were questioning God,” Amanda recalled.

The family say they battled for months to get medical records, only to find they were inaccurate and incomplete.

Two key documents requested on the day of Adam’s death were not given to the family, who were later told they no longer existed because they were on machines that only stored data for three months. The hospital insisted the documents were not destroyed but “overridden”.

The family were blindsided to finally learn the true sequence of events when they received an apology and a copy of the root cause analysis in February.

Photos of Adam Fitzpatrick in Jugiong.

Photos of Adam Fitzpatrick in Jugiong.Credit:Dominic Lorrimer

After receiving the news, Philippa was hospitalised with takotsubo cardiomyopathy, also known as broken heart syndrome, where the heart muscle is weakened by an intense surge of stress hormones.

An investigation found that the ENT officer was away from the hospital and was originally told it was not necessary for him or another doctor to return because the situation was under control.

One of two senior doctors rostered on to the ICU was also absent due to a “personal issue”.

The root cause analysis found there was a lack of clarity as to who was the team leader, equipment was used incorrectly which may have collapsed Adam’s lungs, safety equipment that should have been used was not and Adam’s tracheostomy emergency management plan was inadequate.

It also found “inconsistent evidence” when it examined how recently staff had been trained and assessed in the handling of tracheostomy emergencies.

The original version of the analysis approved by St George Hospital did not identify any root causes of Adam’s death or make any recommendations.

It was changed after it was sent to executives within the South Eastern Sydney Local Health District for review.

‘Incredibly confronting and stressful’

Over the past decade, pioneering work has taken place within the international medical community to curb the number of adverse events involving tracheostomy patients.

The Global Tracheostomy Collaborative was formed in 2012, spearheaded by doctors from the United States, UK and Australia’s Austin Hospital in Melbourne.

They developed a five-prong approach to preventing adverse events, that includes co-ordinated team care, standardisation of care protocols, multidisciplinary education and staff allocation, patient and family involvement, and use of data tracking to drive improvement.

More than 50 hospitals from around the world have joined, reducing the severity of major adverse events involving tracheostomies by 54 per cent and improving overall quality of care through safer, swifter recovery.

Adam, Amanda and Emma Fitzpatrick shared a close bond as siblings growing up in the NSW South West Slopes.

Adam, Amanda and Emma Fitzpatrick shared a close bond as siblings growing up in the NSW South West Slopes.

Associate Professor Michael Brenner, from the University of Michigan School of Medicine, is the collaborative’s president.

He tells the Herald tragic incidents involving tracheostomies are all too familiar for doctors in his field but system-wide improvements can radically reduce their incidence.

Professor Brenner says the accidental dislodgement of a tracheostomy tube is one of the most common adverse events and doctors or other health professionals trying to replace a dislodged tube could often end up pushing it into the soft tissues in the front of the neck instead of successfully placing it into the windpipe.

“Sometimes the catalyst for hospitals to improve tracheostomy care is that something terribly unfortunate has happened,” he says. “We’d really like to get to a place where hospitals preemptively take steps to improve, such as joining the collaborative, before an event happens.”

He drew on the “swiss cheese” model of risk, where a number of holes in the cheese have to line up for a catastrophic event to occur. A multi-prong approach could plug at least some of those holes, Professor Brenner says.

“This story of a family member, knowing that something’s not right and trying to sound the alarm and being unheard, that’s very pervasive in medicine internationally. So if we can just amplify the voice of the patient, that seemingly small act can transform healthcare.”

Dr Stephen Warrillow, director of intensive care at the Austin Hospital, says many of the principles that can reduce adverse events are not overly complicated, but notes individual doctors may not see a patient with a tracheostomy more than a couple of times a year.

“If you’re called urgently to a crisis and it’s many years since you’ve dealt with a patient with a tracheostomy, you’re trying to troubleshoot a difficult problem in a situation where you only have minutes to spare,” he says.

Dr Warrillow says his first concern is always for patients and their families when adverse events occur but notes preventing such incidents also has a profound effect on the healthcare workers involved.

“You come to work to do a good job and look after people, so it’s incredibly confronting and stressful for healthcare workers watching a patient dying and feeling perhaps nothing you’re doing is working.”

‘I feared the next call-out’

St George Hospital’s intensive care unit was barred from training junior doctors in 2019 amid allegations of bullying and dysfunction among senior staff.

The Fitzpatricks have queried whether a bullying culture in the ICU created an atmosphere where junior staff did not feel comfortable asking for help.

Amanda Fitzpatrick says she was a “shadow of my former self” returning to work as a paramedic after watching her parents kiss their son goodbye and bury him.

“I feared the next call-out,” she wrote in a letter to the hospital. “I feared blood and trauma.

“Most of all I feared making a mistake that would end someone’s life, just as your team had done to Adam.”

Emma Fitzpatrick, a lawyer, has moved into the medical negligence sector since her brother’s death to help other families find justice.

“We’re 15 months down the track and it feels like nothing has been done and we haven’t gotten anywhere despite hours and hours and hours of heartache, anguish and effort,” she says.

Hospital managers admit they have not been able to “adequately answer” the family’s questions arising from the root cause analysis, partly because some clinicians involved no longer work at the hospital.

They promised an external investigation, which was called off last month so as not to interfere with investigations by the State Coroner.

The family is also pursuing legal action, but can only sue for their own nervous shock because, unlike other jurisdictions, the NSW legal system does not recognise “wrongful death”.

“It’s not about the money as such, but that his life is valued so little,” Philippa Fitzpatrick says.

A St George Hospital spokeswoman acknowledged Adam Fitzpatrick did not receive the care he deserved in August 2020.

A St George Hospital spokeswoman acknowledged Adam Fitzpatrick did not receive the care he deserved in August 2020.

The root cause analysis document is also not admissible in court, on the basis this encourages clinicians to be more frank and truthful in their accounts.

Ms Fitzpatrick now struggles with feelings she failed Adam by not doing more to escalate her concerns about the tracheostomy on the day of his death.

“Adam’s death was completely preventable,” she says.

“We have lost our most precious son, and more importantly he has lost his whole future, and this has happened in completely unacceptable circumstances. We want to ensure that this does not happen to other families.”

She says it is frightening to think other preventable deaths may be swept under the rug where families lack medical knowledge to challenge what they are told.

“We want people to know these cover-ups do happen.”

A St George Hospital spokeswoman acknowledges Adam Fitzpatrick did not receive the care he deserved in August 2020 and the hospital extended a sincere apology to his family.

She says the hospital is fully co-operating with an independent investigation by the NSW Coroner.

“St George Hospital is committed to processes that result in learning from incidents and to improving the care we provide to our patients,” the spokeswoman says.

WATCH: See the Fitzpatrick family’s story on A Current Affair on Monday at 7pm on Channel Nine.

The Morning Edition newsletter is our guide to the day’s most important and interesting stories, analysis and insights. Sign up here.

Next Post

latest collection by Jihansyakira

Wedding season is in full swing, and Jihan Syakira has created some of her latest favorite collections with the perfect modern fashion inspiration. Fashion Desaigner Tips & Tricks for Storing Wedding Dresses A wedding dress is undoubtedly one of the most valuable pieces of clothing you will ever own. Therefore, […]