Introduction

A recent coronial inquest in South Australia has highlighted particular risks faced by small private hospitals and their insurers when high risk patients are admitted for surgery.  Both John William Ryan and Patricia Dawn Walton died following orthopaedic procedures at an Adelaide private hospital.  South Australian Deputy Coroner Elizabeth Sheppard held a joint inquest into the deaths. 

The death of John Ryan

Mr Ryan was admitted for ankle surgery at Sportsmed in March 2008. At 6am the next day he was found unconscious by a nurse. After a delay, ambulance officers were called to the hospital. During the retrieval process to Royal Adelaide Hospital, he suffered a cardiac arrest. The Coroner found Mr Ryan died from acute respiratory failure secondary to a combination of the opiate medication received following his surgery.17

On the day of his surgery Mr Ryan’s anaesthetist was changed at the last minute resulting in no pre‑anaesthetic consult arranged in advance of surgery. The Coroner found the admission process denied Mr Ryan the benefit of a timely anaesthetic consult to assess his level of risk and suitability for admission.18

Based on Mr Ryan’s morbid obesity and physical characteristics alone, he should have been assessed pre-operatively as a higher risk patient requiring monitoring in a High Dependency Unit (HDU) the night following his surgery. However at the time of Mr Ryan’s admission to Sportsmed the non-accredited HDU was unavailable.  Without a functioning HDU at Sportsmed, the Coroner found Mr Ryan should not have been admitted for his surgery.19

There were no medical practitioners in the hospital overnight; only nursing staff. During the night Mr Ryan’s PCA line failed and was removed. Opiates in the form of morphine and Capadex tablets were later administered. Evidence from the nurses working throughout the night shift leading up to Mr Ryan’s death described it as very busy – a common occurrence. In this environment Mr Ryan received only cursory attention over a period of four hours, followed by a delayed and deficient response to his dangerous condition by inexperienced nursing staff at 6am.20

The Coroner found Mr Ryan’s death could have been prevented; had his deterioration been detected earlier, the anaesthetist could have been contacted in time to reverse the effects of the respiratory depression caused by the opioid medication.21

The death of Patricia Walton

Ms Walton was admitted on 26 October 2010 for a total left hip replacement. She suffered acute deterioration in the early hours of the sixth day after her surgery. She was subsequently transferred to the Royal Adelaide Hospital on 1 November where tests revealed she had suffered irreversible brain damage. Ms Walton passed away on 2 November 2010 following a cardiac arrest,22

The Inquest considered whether Mrs Walton should have been assessed as appropriate for surgery at Sportsmed due to the limitations of the care available in the event of complication. During the Inquest independent anaesthetists and intensivists gave  evidence critical of Sportsmed’s systems and facilities for coping with the specific challenges posed by a patient such as Ms Walton post-operatively

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At the time of her admission into Sportsmed Ms Walton weighed 126.5 kilograms and had a number of challenging comorbidities including BMI, adverse drug reactions, anaesthetic difficulties and sleep apnoea.23

The Coroner found the surgeon should have specifically discussed these risks with both the patient and the physician before admitting Ms Walton to Sportsmed.24 Instead, due to an administrative error, Ms Walton had no opportunity for a timely anaesthetic consult.25

Five days after surgery Ms Walton’s condition deteriorated. In the early evening she became wheezy and short of breath, nurses contacted the physician by phone, and Ventolin was prescribed. Throughout the night, with the physician remaining contactable only by phone, Ms Walton’s condition steadily worsened. By 3.40am the nurse in charge of her care failed to recognise the urgency of her situation and delayed for ten vital minutes before calling the physician. At this time, an ambulance was called by another nurse to transfer her to Royal Adelaide Hospital.26 At 4:07am Ms Walton suffered cardiac arrest resulting in irreversible brain damage.27

The Coroner determined Ms Walton’s care had been mismanaged by nursing staff, concluding Ms Walton should not have been admitted for surgery at Sportsmed; reporting its medical and nursing resources inadequate to handle her complex requirements.28

Coroner’s recommendations and implications

As a result of the Inquest, the Coroner recommended accreditation requirements be adopted for small hospitals without on-site medical practitioners overnight and Intensive Care Unit  backup in order to develop robust pre-admission processes for high risk patients.  The Coroner also recommended that hospitals with staff and facilities similar to those at Sportsmed should consider the implementation of a policy declining to admit higher risk patients to their facilities.29

The Coroner’s findings pose challenges for private health care facilities – again highlighting that careful patient vetting procedures, adequate staffing, and strong internal processes are needed if complex surgery is to be performed at and high risk patients are to be admitted to smaller facilities.  The Inquest also highlights some of the risks which insurers need to consider when underwriting risks at private hospitals which are not attached to larger public hospitals.