Pa­tient safety at risk: coro­ner

Mercury (Hobart) - - NEWSFRONT - HE­LEN KEMP­TON

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.”

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