'Horrific' hospital mix-up remains unresolved

An elderly man whose bladder burst and lungs collapsed after an oxygen tube was inserted into his catheter was unlikely to have done the fatal deed himself, an inquest has found.

SA Coroner Mark Johns said it was “implausible” that former Socceroo Stephen Herczeg, 72, caused his own “cruelly painful death” but that he couldn’t rule it out.

The coroner said the most pressing issue in the inquest was to answer the question of how the oxygen supply came to be connected to Mr Herczeg's catheter in September last year at Adelaide’s Queen Elizabeth Hospital.

The court heard that Mr Herczeg was receiving oxygen via a nasal cannula from the oxygen supply at the bedside. He also had an indwelling catheter to drain his bladder.

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Despite evidence that Mr Herczeg was in a confused state and was known to fiddle with his tubes, in the coroner’s opinion, it was unlikely that he killed himself “because of the complexity of the task and the multiple manoeuvres”.

Mr Johns also noted that there was no evidence of a deliberate mix-up.

"However, I cannot exclude the possibility that he did it himself — implausible as it seems. I therefore find that the tubing was interfered with by an unknown person."

Mr Johns described Mr Herczeg’s death as “horrific”.

“It was traumatic, and there is no doubt that Mr Herczeg was in severe pain as a result of the mechanism of death,” he said.

“In the awful and macabre circumstances of Mr Herczeg’s death, his body filled much like a balloon, causing internal disruption. The pressure of the gas prevented him from being able to fill his lungs and he died because he could not breathe.”

The other obvious source of pain was the rupture of the bladder, he added.

Mr Johns also noted evidence that Mr Herczeg was “yelling and screaming” before he was discovered by staff.

“It goes without saying that this event should not have happened.”

Mr Johns ruled that the death was caused by bilateral pneumothoraces and pneumoperitoneum due to “insufflation of the bladder with rupture”, as well as an infective exarcebation of COPD. 

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Coroner's findings