Gary Wilmshurst. File photo from APN
A Wellington grandfather who died two days after falling
from a stepladder was sent home from hospital with painkillers
by a doctor who "seriously underestimated" his injuries, an
inquest has been told.
Gary Donald Wilmshurst had been sanding the outside of his
house in Porirua when he fell one metre and landed in a
tiered rock garden on Boxing Day in 2011.
Two days later, on his 62nd birthday, he collapsed and died
as family members arrived to celebrate his birthday.
An inquest into his death was heard before Coroner Ian Smith
in Wellington today.
The inquest was told medical staff at Kenepuru Hospital's
accident and medical centre did not order a chest x-ray,
which could have revealed fractures to his ribs.
Instead, Dr Philip Gartland diagnosed Mr Wilmshurst with
bruising of the ribs, ordered a tetanus injection and
prescribed painkillers before sending him home.
A post-mortem examination found Mr Wilmshurst died of
blunt-force trauma to his chest. His injuries included eight
fractured ribs, a collapsed lung, and internal bleeding in
his chest cavity.
Emergency medicine expert Dr Peter Freeman, who prepared a
report for the coroner, told the inquest it was clear that Dr
Gartland had "seriously underestimated" the injuries.
He said if an x-ray had been ordered, the fractures would
have been clearly visible and Mr Wilmshurst would have been
admitted to hospital, where the complications may have been
Dr Freeman said the injuries were recorded as having happened
on the previous day, rather than two hours before the
examination, and it was possible Dr Gartland had given
insufficient time to patient history.
Appearing by video link from New South Wales, where he now
works, Dr Gartland said it was standard practice to order a
chest x-ray if a patient had difficulty breathing, and to
order blood tests if a patient was tender.
However, he did not do so because Mr Wilmshurst had only
minor bruising and there was no evidence he had suffered an
Dr Gartland said there had been an "unforeseen and tragic
outcome" and apologised to the family for the documentation
He said it was possible the CPR performed on Mr Wilmshurst
had been responsible for some of the rib fractures.
Dr Freeman agreed it could explain some fractures, but it was
highly unlikely to be responsible for all eight.
Kenepuru Hospital's accident and medical centre clinical
leader, Dr Jane Kelly, said a review had taken place. She
agreed it had found the decision not to perform an x-ray was
A separate investigation by the Health and Disability
Commissioner had found the standard of care was appropriate.
Dr Kelly said extra triage training since had been
Mr Wilmshurst, who was married to his wife Maureen for 40
years, and had two children and two grandchildren, was
described as a good handyman who did most of the home
Constable Keith Stevens told the inquest Mr Wilmshurst had
discussed using scaffolding to paint parts of the house where
the ground was uneven, but on the day of the fall, he set to
work sanding the facia from a two-step ladder.
"The ground was uneven and when Gary reached too far, the
ladder toppled over and he fell into a tiered rockery
Mr Wilmshurst was able to stand up and make it to a chair
inside his house, but he was in "extreme pain" as his wife
drove him to hospital.
When he returned home, he found it too painful to move or lie
down, despite the painkillers, so he mostly remained in a
Two days later, he was concerned about his condition and left
a message with his doctor.
But by that afternoon, when family members had arrived to
celebrate his birthday, he had turned pale and his breathing
had sped up. He collapsed and attempts to revive him were
Coroner Smith reserved his findings.