Craig Rose recalls catching up in a pub with his best friend of 35 years, Kenneth Toll, when they saw two old men sitting and laughing together at another table. Toll gave Rose a nudge and said: “That’ll be us one day”.
Toll was wrong.
Toll, an active 62-year-old, died on 20 July 2019 after undergoing a low-risk elective bilateral knee surgery at Albury Wodonga private hospital in New South Wales. He was found on the floor of a hospital bathroom three days after surgery; he had collapsed after a shower and hit his head as he fell.
When Toll’s son rushed to the hospital after finding out his dad had died, he arrived to see Toll still on the floor, lying in blood, family members told Guardian Australia.
The family want answers about how Toll, a type 2 diabetic with hypertension and an extensive list of other health issues, died from a surgical procedure considered routine for knee pain.
Toll wanted the operation as he hoped it would allow him to travel more frequently to visit Rose in Canberra and to explore Europe with his wife of 40 years, Wendy Toll.
This week, Toll’s family and many loved ones attended all five days of a coronial inquest into his death at Albury local court. “I’m here because I loved him and I love his family,” Rose said.
The coroner will examine whether Toll should have been assessed as fit for surgery, whether his risk for complications was adequately assessed and whether the surgical techniques used by his surgeon, Dr Elie Khoury – including using metal bars and guiding devices called rods and performing two surgeries at once – affected risk.
The coroner will also consider whether Toll was cared for appropriately in the three days after surgery.
A question that repeatedly arose was whether Toll should have been referred to and assessed by a cardiologist when he began to experience episodes of supraventricular tachycardia, or an elevated heart rate, after surgery.
Medical notes state Toll was also clammy, nauseous and vomiting and his oxygen and haemoglobin levels had dropped.
Associate Prof Mark Adams, a Sydney cardiologist and expert witness, told the coroner that Toll’s first episode of supraventricular tachycardia would have been a concern given the length of time the episode lasted and the other symptoms he was experiencing.
“I would think of referring to a cardiologist,” Adams said in court on Thursday. When Toll experienced two further episodes, Adams said he would have hoped a “fairly rapid” referral to a cardiologist would have occurred, especially since prior to the surgery Toll had never experienced the condition before.
Another expert witness from Sydney, the orthopaedic surgeon Dr Myles Coolican, agreed. He said, in his opinion, Toll’s post-operative care was not adequate.
He said Toll’s tachycardia, combined with low haemoglobin and low oxygen, would have led him to start treatment with anticoagulants and to organise further tests in case of a pulmonary embolism (a blood clot that travels to the lungs). He said a review from a cardiologist or general physician should have been sought.
Toll’s orthopaedic surgeon, Khoury, told the inquest while he could not recall making a referral to a cardiologist “I think that’s what I would have done”.
He told the court he thought he would have made a referral to Albury cardiologist Dr Jan du Plooy on 18 July 2019 “and it would have been my practice to do so”.
Du Plooy told the court on Thursday that Toll was never referred to him and that Toll was never his patient.
Du Plooy recalled a nurse asking him to look at an electrocardiogram image he believed belonged to Toll. But he said the nurse was simply asking questions for her own education purposes and it was not a consult for medical advice.
He said he recalled the nurse making a comment Toll may be referred to him, but he said at no point was a referral made.
Du Plooy reviewed all of his clinic’s medical records and phone records to confirm no call or paperwork came during that time period that could have been a referral or request to review Toll.
The court heard there was no record, including notes or phone logs, recording Khoury having referred Toll to a cardiologist after the surgery.
At the end of his evidence, du Plooy addressed the Toll family directly, expressing his condolences. He told the court he was shocked when he heard Toll had died.
Under cross-examination it was put to Khoury he did not make any referral to a cardiologist. “I reject that proposition,” Khoury said.
The court heard from Khoury he did not routinely look at a patient’s medical records when conducting his ward rounds because he was reliably updated by nurses about a patient’s progress.
“I see them, I talk to them. If there’s any issue with their [the patient’s] oxygenation or other issues I am always notified by the nurses,” he said.
Khoury said he also believed Toll’s tachycardia was being well managed and that he was not trained to look at an echocardiogram.
Khoury said he believed Toll was being well-managed post-surgery by his anaesthetist, Dr Graham Libreri. Libreri told the court his key role was in the 24 hours post-surgery to manage the patient’s pain and any anaesthesia-related symptoms.
Libreri also said he gave Toll his heart medication intravenously due to the vomiting and thought his failure to absorb the oral medication may have caused the initial tachycardia, but he also suggested to Khoury that Toll be referred to a cardiologist.
Khoury was questioned for most of the day on Wednesday. Under cross-examination he confirmed as of November 2019 he had performed 94 bilateral knee replacements at Albury Wodonga private hospital.
The hospital is managed by Ramsay Health Care, Australia’s largest private hospital operator.
Under cross-examination Khoury confirmed – of those 94 patients – he had a death rate of 3%.
Khoury argued the 3% death rate information was out of context, given in the decade prior to Toll’s death he had performed more than 1,600 knee arthroplasty procedures across different hospitals and therefore his overall death rate was within the acceptable range.
Khoury said he did not see the family in the hospital after Toll died and he did not realise they were there. But family members told the Guardian Australia Khoury saw them but did not approach.
Friday was supposed to be the final day of evidence at the inquest. But last-minute submissions from lawyers representing Ramsay Health Care Australia’s chief nurse, Dr Bernadette Eather, prompted the coroner to adjourn the court to hear her evidence at a later date.
The coroner said this was to give the parties time to consider Eather’s submission in case it should give rise to further investigations.
About 600 people attended Toll’s funeral in Albury in August 2019, requiring a television screen and seats in a car park to accommodate the large group of mourners. The Toll inquest also attracted many people and an overflow room was required to accommodate everyone.
Rose spoke on behalf of the family on Friday, addressing the coroner and the court as he read their statement.
He said the family had been deeply traumatised after seeing Toll dead on the floor at the hospital. Rose said so many people had seen his friend’s dead body lying there that Toll’s wife, Wendy, had heard one of her neighbours boasting about having seen it in the days after.
He said Wendy was struggling to navigate life without her husband.
The family had trusted the hospital and staff, Rose said, and held the “belief Dr Khoury would do everything in his power to perform the surgery and keep him safe after”.
They never anticipated Toll would not survive what they believed to be a routine surgery, he said. The family wanted change to keep other patients safe and so no other family would have to endure their pain, he added.
Speaking to the Guardian about his friend who he’d served alongside in the army, Rose said: “A lot of people know a lot of people.
“It doesn’t mean everyone loves them. For him [Kenneth], everyone he came across had a connection with him and loved him.”
