Patient safety at risk: coroner
A TASMANIAN coroner has put the state’s health service on notice, saying overcrowding at the Royal Hobart Hospital needs to be fixed in the name of patient safety.
Coroner Rod Chandler raised his concerns in his findings into the death of fatherof-three Stephen Bruinger from a brain haemorrhage at the RHH in January last year.
The 62-year-old was misdiagnosed upon presentation at the emergency department and given inappropriate medication. But Mr Chandler said he accepted a doctor’s evidence that the 62-year-old would have likely suffered a second cerebral bleed and died despite that. He said his real concerns were around overcrowding in the ED, which meant the patient was not monitored adequately.
“A matter of real concern arising from this investigation is the report of Dr Emma Huckerby and her opinion that the overcrowding in her ED prevented Mr Bruinger from receiving, for a period of eight hours, the appropriate level of monitoring which his condition required,” Mr Chandler said.
“While the incapacity to better monitor Mr Bruinger was not, in the circumstances of his case, a factor causative of his death, the state of affairs as described by Dr Huckerby had the prospect of seriously compromising patient safety.
“In this circumstance it behoves those persons responsible for the management of the RHH to investigate the situation and to adopt changes which prevent or at least sig- nificantly reduce the prospect of its repetition.”
Dr Huckerby, the director of the ED at the Royal, told the coroner Mr Bruinger should have been allocated a monitored cubicle so his vital signs could be observed.
“Due to extreme ED overcrowding there was no capacity for this to occur for more than eight hours,” she said in evidence. “The patient experienced an intercerebral bleed, was admitted to ICU and subsequently died,” the transcript of her evidence said.
“Hour audits of the ED capacity over this time period showed that at all times there was ambulance ramping, no availability of acute ED cubicles, and for seven hours there was access to zero or one resuscitation cubicle.”
Mr Bruinger’s death was not reported to the coroner for eight days.
“Before Mr Bruinger’s death had been reported to the coroner his body had been released to his family for burial or cremation. As a result the coronial investigation has not been aided by a post-mortem examination,” Mr Chandler said.
A Tasmanian Health Service spokesman said: “The THS notes the coroner found that levels of demand in the emergency department were not causative of Mr Bruinger’s death.”