Click photo to enlarge
David Crerar.
The death of an intellectually handicapped man after
collapsing and being trapped in a toilet at the Oamaru Hospital
emergency department in October last year was yesterday the
subject of an inquest in the Coroner's Court in Oamaru.
The incident has prompted Otago-Southland Coroner David
Crerar to send his findings on the death to Minister of
Housing Maurice Williamson with a recommendation he consider
changing the building code to address the issue of toilet
doors, particularly in areas like an emergency department,
having external access through inward opening doors.
Oamaru Hospital has already started to change its toilet
doors to provide an outward-opening portion which can be used
by staff if a similar incident occurred.
Dean Roland Smith, of Oamaru, who also suffered from
epilepsy, was admitted to the hospital's emergency department
on October 10 at 7.55am.
He died about 1.10pm after collapsing about 12.15pm and being
trapped in the toilet.
He collapsed with his head against the inward-opening door.
Hospital staff could not force their way in because they
feared they could severely injure his neck, head or spine.
A builder from a neighbouring building site used power tools
to cut away half the door so Mr Smith could be attended by a
doctor and removed from the toilet.
Mr Crerar found Mr Smith died from asphyxia during a
convulsion when he was trapped in the toilet, delaying
appropriate resuscitation efforts by medical staff.
Mr Smith's sister, Heather Diann Vincent, of Oamaru, said her
brother was handicapped from a significant brain injury when
he was 3.
He also suffered from epilepsy.
About 7.30am on October 24 he was taken by ambulance to
Oamaru Hospital, where he was treated and medication
administered.
While being treated, he wanted to go to the toilet and was
assisted by Mrs Vincent in a small public toilet at the
emergency department.
She said the public toilet was very small and she had
difficulty helping her brother.
Nurse Sharief Kamel said that about noon, Mr Smith wanted to
go to the toilet again.
About 12.15pm, Mr Kamel heard "a loud crash" from the toilet
and went back, asking Mr Smith if he was all right.
Mr Smith did not answer him.
Mr Kamel found he could not open the door.
He eventually managed to push it ajar about 10mm.
In a mirror, Mr Kamel could see Mr Smith lying on the floor
with his head against the door.
Mr Kamel estimated Mr Smith was trapped in the toilet for
about 30 minutes.
Attempts were made to revive him but were discontinued when
it was established there was no brain activity.
Mr Crerar is requesting further information from Oamaru
Hospital on some issues raised during yesterday's inquest,
which he directed not be published until the information was
received and he issued his written decision.
He also said he had made inquiries with the Waitaki District
Council about the toilet door and was told it complied with
the building code.
However, Mr Crerar believed that was flawed - particularly in
areas like a hospital emergency department.
In such areas, it was more likely a patient could collapse
while using a toilet, so the door should have some access
opening outwards.
