Hospital deaths: doctors cleared
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.