Hospi­tal deaths: doc­tors cleared

The Australian - - THE NATION - MICHAEL OWEN

A coro­ner has made no rec­om­men­da­tions af­ter an 18-month in­ves­ti­ga­tion into the deaths of two stroke pa­tients in the Royal Ade­laide Hospi­tal when both its stroke spe­cial­ists were on leave be­cause of a ros­ter­ing er­ror.

But South Aus­tralian Coro­ner Mark Johns, who yes­ter­day handed down his find­ings in a 59-page re­port, said it was “ex­traor­di­nary” a re­cruit­ment search for a third neu­ro­ra­di­ol­o­gist was aban­doned for bud­getary rea­sons in 2016, de­spite the clear need for back-up. He also crit­i­cised a fail­ure of hospi­tal au­thor­i­ties to im­me­di­ately in­form him of the deaths, say­ing they were “clearly re­portable”.

“The con­clu­sion is in­escapable that the de­ci­sion to halt the re­cruit­ment process was mo­ti­vated by bud­getary con­sid­er­a­tions ... it is ex­traor­di­nary that a clear need for a third (spe­cial­ist) at the Royal Ade­laide Hospi­tal was over­looked and set aside by what can only be de­scribed as a bu­reau­cratic re­sponse to a highly reg­u­lated and in­dus­tri­alised set of em­ploy­ment prac­tices,” Mr Johns said.

The Coro­ner also crit­i­cised one of the two RAH spe­cial­ists, Re­becca Scroop, who he said “ex­er­cised in­flu­ence in re­la­tion to the pro­vi­sion of INR ser­vice within the state’s pub­lic hospi­tal sys­tem and at­tempted to ef­fec­tively dom­i­nate all de­ci­sion mak­ing in that sphere”.

He found Dr Scroop’s per­sonal dis­like of a ra­di­ol­o­gist based at the Flin­ders Med­i­cal Cen­tre, Steve Chrys­sidis, mo­ti­vated her to try to avoid hav­ing him fill in at the RAH.

“One of the cir­cum­stances that cre­ated the un­sat­is­fac­tory sit­u­a­tion ... was that Dr Scroop, hav­ing vol­un­teered to make an ar­range­ment ... in the rel­e­vant pe­riod (of ab­sence) failed to con­sider what must be re­garded as an ob­vi­ous so­lu­tion to the prob­lem, the re­cruit­ment of Dr Chrys­sidis,” Mr Johns found.

“The only con­clu­sion that can be reached is that she would not do so be­cause of the per­sonal an­tipa­thy be­tween them.”

Michael John Rus­sell, 60, and Les­lie Robert Gra­ham, 87, died in April last year while the hospi­tal’s only two stroke spe­cial­ists, Dr Scroop and James Tay­lor, were on an­nual leave.

Dr Scroop was over­seas and Dr Tay­lor was fish­ing near Vic­tor Har­bor, south of Ade­laide, and only avail­able to be called in for non-ur­gent cases, with a “patchy” phone line.

The in­quest had heard Dr Chrys­sidis gave emer­gency treat­ment to Mr Rus­sell and Mr Gra­ham. There were com­pli­ca­tions and both died.

The Coro­ner’s re­port said the RAH stroke team was con­fused about who to con­tact on April 18 last year. But Mr Johns found Dr Chrys­sidis’ con­duct of the pro­ce­dures on both Mr Gra­ham and Mr Rus­sell took place within ac­cept­able time lim­its and the “un­for­tu­nate out­comes” were not the re­sult of the ab­sence of ei­ther Dr Tay­lor or Dr Scroop.

Mr Johns said Dr Scroop “cer­tainly ran an au­ton­o­mous INR ser­vice at the Royal Ade­laide Hospi­tal and her in­flu­ence in that ser­vice was dom­i­nant”. “It is rea­son­able to con­clude a sig­nif­i­cant part of her mo­ti­va­tion was to avoid the very sce­nario that even­tu­ated, namely the par­tic­i­pa­tion of Dr Chrys­sidis in any as­pect of the INR ser­vice at Royal Ade­laide Hospi­tal,” Mr Johns found.

Newspapers in English

Newspapers from Australia

© PressReader. All rights reserved.