Record of Investigation into Death (Without Inquest)
Coroners Act 1995
Coroners Rules 2006
I, Rod Chandler, Coroner, having investigated the death of
Aliesha Emily Hayers
WITHOUT HOLDING AN INQUEST
(a) Aliesha Emily Hayers (“Aliesha”) was born on 10 April 1994 and was aged 17 years.
(b) Aliesha died on 29 February 2012 at her place of residence being 8568 Huon Highway at Southport.
(c) Aliesha died of acute asthma.
(d) No person contributed to the cause of Aliesha’s death.
Since her mother’s death in 2008 Aliesha had been cared for by her maternal grandmother, Mrs Jennifer Noelene Hayers. Aliesha, along with her brother Bradley, were living with Mrs Hayers at her home at Southport. Aliesha’s partner Dale Robert Williams was also living with them at the same address. Southport is about 95 km south of Hobart.
Aliesha had suffered from asthma since birth. Her condition was managed with the assistance of her general practitioner Dr Robert Hamilton who prescribed her medication regime. This comprised Seretide MDI, 125/25, an asthma preventative to be taken via two inhalations per day, together with a Ventolin inhaler, an asthma reliever to be taken via one to two puffs four hourly as required.
In October 2011 Aliesha fell pregnant and was carrying a 21 week male foetus at the time of her death.
Circumstances Surrounding the Death
On 17 February 2012 Aliesha experienced an exacerbation of her asthma. She had been suffering an upper respiratory tract infection for one week beforehand. The exacerbation was sufficiently serious to require her transport by ambulance to the Royal Hobart Hospital. She was seen in its Emergency Department. (‘the ED’) Her symptoms were settled with the use of salbutamol via a spacer device. Aliesha was discharged with a salbutamol puffer and spacer. She was advised to return to hospital if her symptoms recurred and they could not be managed at home. The ED was aware that she had an appointment to see Dr Hamilton in three days’ time.
On 20 February Aliesha did attend Dr Hamilton. Beforehand he had received a letter from the ED and was therefore aware of Aliesha’s recent asthma attack and the treatment received in the hospital. At the time of his consultation Dr Hamilton believed that Aliesha had substantially recovered from the recent episode. He recorded that she was feeling well and was excited about her pregnancy. He instructed her to continue her medications “as usual” and he did not make any alterations to the regime which I have set out above.
At about 7.30 am on 29 February Aliesha began feeling unwell with symptoms of asthma. She was still in bed. Mr Williams obtained her puffer for her (likely to have been the salbutamol puffer provided by the Emergency Department) and she took about four puffs of this. About one hour later Aliesha was still suffering symptoms. By this time she had got up and was in the kitchen. She complained of shortness of breath. She appeared pale and was wheezing. Her grandmother helped her to use a salbutamol nebuliser. However, her breathlessness persisted. At about 9.00 am she collapsed to the ground. Mrs Hayers, who was also an asthma sufferer, has a home oxygen device and this was applied. However, Aliesha did not regain consciousness.
Records from Ambulance Tasmania show that an emergency 000 call was received reporting that a patient, namely Aliesha, was having breathing difficulties. The closest available ambulance crew was at Hobart and it was assigned to the case. It was 72 minutes before the ambulance arrived at Aliesha’s residence. In the meantime Ambulance Tasmania had received further calls advising of Aliesha’s deteriorating condition, particularly a call at 9.05 am reporting that she was not breathing. At this time family members began CPR as directed from Ambulance Tasmania’s radio room and this was maintained until the ambulance’s arrival.
Once paramedics were on the scene they continued the resuscitation efforts. However, they were unsuccessful in resuscitating Aliesha and she was declared deceased at 10.15am.
The coronial investigation of the circumstances surrounding Aliesha’s death has included the following:
(i) A post-mortem examination undertaken by State Forensic Pathologist, Dr Christopher Lawrence.
(ii) The obtaining of affidavits from Mrs Hayers, Ms Debra Oakford, an aunt of Aliesha and Mr Williams.
(iii) Obtaining a report from Dr Hamilton.
(iv) Obtaining a report from Dr Ingrid Smethurst of the RHH.
(v) Obtaining a statement from Dr Boon Lim.
(vi) A review of Aliesha’s records at the RHH undertaken by Research Nurse, Ms Libby Newman.
(vii) Receiving a report from Ambulance Tasmania.
(viii) Obtaining advice in conference with Dr Lawrence, Ms Newman and Clinical Professor A J Bell as medical adviser to the Coroner.
Dr Lawrence has provided a report upon his post-mortem examination. In that document he notes that the autopsy revealed lung changes “consistent with severe asthma.” In his view the cause of Aliesha’s death was acute asthma. I accept this opinion.
The investigation has given rise to two significant issues. The first relates to Aliesha’s asthma medication. The second concerns the adequacy of the response by Ambulance Tasmania. I will deal with both these matters in turn.
Mr Williams says in his affidavit that when Aliesha became pregnant Dr Hamilton advised that she should not “use the Seretide as often as it contains steroids and may affect the baby (sic) weight.” In a similar vein Ms Oakford says in her affidavit that she was present with Aliesha in the ED on 17 February when she was advised by a doctor “that he would take her off the Seretide puffer she uses as it contains steroids and may harm her unborn baby…” Even accepting that these comments may have been made, it is clear that neither the ED nor Dr Hamilton considered it appropriate for any change to be made to Aliesha’s prescriptions. Nevertheless, it is possible that Aliesha, believing it to be in the best interests of her unborn infant, did either cease or reduce her usage of Seretide after she became pregnant. If she did, and I am unable to make a positive finding upon this, it is not known whether any change to her medication intake was, in all likelihood, a factor relevant to the onset of her fatal asthma attack on 29 February.
The circumstances of this case have caused me to investigate the recommended course to be taken by asthma sufferers with respect to their medication during pregnancy. Dr Boon Lim is the Director of Obstetrics and Gynaecology at the RHH. He has advised that:
• The pharmacological treatment of asthma during pregnancy should be the same as in the non-pregnant state.
• If oral corticosteroids such as Seretide are clinically indicated for an exacerbation they should not be withheld because of pregnancy.
• If maintenance treatment with inhaled corticosteroids including Seretide was necessary before the pregnancy, it should be continued during pregnancy.
• As in the non-pregnant state, the dose should be the minimum necessary to control symptoms and maintain normal or best lung function.
• Most medications for asthma have good safety profiles in pregnancy.
I accept Dr Boon Lim’s opinions. It is important that female asthma sufferers and their treaters are aware of this advice. To this end I will ensure that these findings are brought to the notice of the Asthma Foundation and to the Royal Australian College of General Practitioners for the information of their constituents.
I now turn to the second issue.
I am informed that Ambulance Tasmania conducted its own investigation of its response in this case and I have been provided with copy of its report. This document shows:
• That the first 000 call was received at 8.27am. The call was classified as an ‘emergency.’
• At the time of the first 000 call:
1. The two ambulance crews based at Huonville were unavailable having been assigned to two separate emergencies, one at Huonville and the other at Cygnet.
2. The crew attending the Huonville emergency had sought backup because of the patient’s condition and at 8.01am the ambulance located at Kingston had been assigned to attend as that backup.
3. There were two ambulance crews available at the Hobart station.
4. There was an ambulance vehicle housed at Dover for use by the one volunteer who was resident in that area. However, that volunteer was not rostered for duty.
• That at 8.31am one of the Hobart crews was assigned to Aliesha’s case. At the same time a paged assignment was sent to Dover but there was no response, presumably because the volunteer officer was not on duty.
• The Hobart crew departed its station at 8.36 am and arrived at its destination at 9.39 am, that is one hour and 12 minutes after the initial 000 call. This is a reasonable response time given the distance involved.
It is of course regrettable that Aliesha’s urgent need for emergency medical treatment could not be met by an ambulance crew located nearer to her home. However, even if one of the nearer crews had been available it does not follow that emergency treatment would have been administered in sufficient time to save Aliesha’s life. This is particularly the case with respect to the Dover ambulance as its volunteer officer would not have been able to administer, by syringe, the life-saving drugs which Aliesha’s condition demanded.
Comments & Recommendations
In Mr Williams’ affidavit he acknowledges that cigarette smoke was a known trigger for Aliesha’s asthma. Aliesha did not smoke. However, Mr Williams, Mrs Hayers and Bradley Hayers were all smokers. Mr Williams describes the Southport residence as a “particularly smokey environment; especially in the kitchen where we all smoked…” In this instance I am unable to make a positive finding that tobacco smoke was the trigger which brought on Aliesha’s asthma attack on 29 February 2012. Nevertheless, exposure to second-hand tobacco smoke is a known risk factor likely to trigger an asthma attack and this case presents me with an opportunity to remind smokers to take every precaution to ensure that asthma sufferers within their households are not exposed to the harmful by-products of their habit.
I have decided not to hold a public inquest into this death because my investigations have sufficiently disclosed the identity of the deceased, the time, the place, the relevant circumstances concerning how Aliesha died, and the particulars needed to register her death under the Births, Deaths and Marriages Registration Act 1999. I do not consider that the holding of a public inquest would elicit any important information further to that disclosed by the investigation conducted by me. The circumstances of Aliesha’s death do not require me to make any further comment or recommendations.
The information which has been presented to me indicates that Aliesha was a young lady with real potential. It is a tragedy that such potential will not be realised. I conclude this matter by conveying my sincere condolences to Mr Williams and to Aliesha’s family.
Dated the 18 day of October 2013 at Hobart in the State of Tasmania.