Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Rod Chandler, Coroner, having investigated the death of

Betty Joy SULLIVAN

WITHOUT HOLDING AN INQUEST

Find That:

Betty Joy SULLIVAN ("Mrs Sullivan") died on 18 March 2007 at the Royal Hobart Hospital in Hobart ("the Royal").

Mrs Sullivan was born at Robe in South Australia on 14 March 1928 and was aged 79 years. She was married and retired. She resided at 20 Dinning Terrace, Bordertown in South Australia.

I find that Mrs Sullivan died as a result of congestive cardiac failure due to severe calcific disease of the aortic and mitral valves and acute on chronic renal failure.

Circumstances Surrounding the Death:

On Sunday 11 March 2007 Mrs Sullivan travelled from South Australia to Tasmania to visit her son. She fell ill during the flight and had to use a wheelchair after disembarking from the plane. Over the following two days Mrs Sullivan complained of nausea and listlessness. She ate and drank very little and spent most of the time resting in bed. She resisted seeking medical assistance.

On Wednesday 14 March 2007 Mrs Sullivan agreed that she should see a doctor. Attempts to obtain an appointment with a general practitioner were unsuccessful. In the result her son took her to the Department of Emergency Medicine (DEM) at the Royal. Mrs Sullivan had with her a letter from her general practitioner in South Australia. It noted a past history of acute myocardial infarction (in 1981), ischaemic heart disease, non-insulin dependent diabetes mellitus, atrial fibrillation, iron deficiency anaemia, congestive cardiac failure and a valvular condition.

At DEM Mrs Sullivan was triaged at 10.14am. She was noted to have renal failure, anaemia, a leaking heart valve and a four day history of nausea and diarrhoea. She was allocated a triage category of 4.

Mrs Sullivan was asked to wait in the waiting area. At about 5.00 pm a nurse checked her vital signs and she was then returned to the waiting area. At about 7.00 pm a doctor announced that there were no beds or cubicles available. He said that patients could elect to wait if they wished but they may prefer to go home as there was little prospect of them being seen by a doctor within a reasonable time. Mrs Sullivan chose to go home. She had been at DEM for almost nine hours without being medically examined or receiving any treatment.

The following day Mrs Sullivan continued to feel nauseous and listless but she was able to tolerate a small amount of food and liquid. However, on the Friday she complained of feeling worse. This time the family was successful in obtaining an appointment for Mrs Sullivan to see Dr Haas, a general practitioner, at Lenah Valley. Dr Haas found that she had abdominal pain. He suggested that Mrs Sullivan return to the Royal. In advance of her arrival he faxed his notes to the Royal for its assistance. Mrs Sullivan’s son took his mother to the hospital. Because of their experience two days previously he spoke to the triage staff and asked how long his mother would need to wait before she could be treated. He was informed that the waiting time was similar to Wednesday’s.

A decision was then made to take Mrs Sullivan to Calvary Hospital and to pay its fee. There, she was examined by Dr Scott McCrossen who diagnosed a urinary tract infection and prescribed medication.

On Saturday 17 May Mrs Sullivan’s condition deteriorated. The family was unsure what to do. An after-hours medical service was contacted. It indicated that there would be a wait for Mrs Sullivan to see a doctor. The alternative was for Mrs Sullivan to be taken back to hospital. Contact was made with Calvary Hospital but it was unwilling to receive her as a patient even though her family was prepared to meet the cost. The decision was then made to call an ambulance. It arrived at about 10.30 pm and Mrs Sullivan was then conveyed to the Royal.

Mrs Sullivan was received in DEM at 11.04 pm and immediately admitted to a cubicle. At 11.18 pm she was seen by an emergency doctor. It was recorded that she had a history of ischaemic heart disease, congestive cardiac failure and chronic renal failure with a previous GFR of 37 in February 07, atrial fibrillation requiring Warfarin, anaemia and Type II diabetes. Clinically it was noted that there appeared evidence of acute on chronic renal failure with a raised creatinine, raised potassium and a raised lactate level. She also had coagulation abnormalities and what appeared to be right lower lobe pneumonia.

At 2.00 am on Sunday 18 May the decision was taken to admit Mrs Sullivan to the Royal. At 1.00 pm that day she was reviewed by an Intensive Care Unit Registrar preparatory to her being admitted to that Unit. However, 20 minutes later Mrs Sullivan suffered a sudden and unexpected cardiac arrest. She was resuscitated and intubated. However, her condition deteriorated and treatment was withdrawn after consultation with family members. Life was declared extinct at 4.05 pm.

Mrs Sullivan’s son reports that he has no complaint about the quality of the medical and nursing treatment provided to his mother after she was taken into their care. However, he is critical of a system which effectively denied his mother access to that care over a period in excess of three days.

A post-mortem examination was undertaken by State Forensic Pathologist, Dr Christopher Lawrence. He determined the cause of death to be being congestive cardiac failure due to severe calcific disease of the aortic and mitral valves with acute on chronic renal failure.

Dr Lawrence also made the observation that Mrs Sullivan had severe underlying disease and "it was of some concern that she could not be reviewed clinically on Wednesday after waiting in the DEM waiting room, as this may have improved her condition". However, he has further commented that Mrs Sullivan’s long-term prognosis was poor given the extent of her underlying disease.

I am satisfied that there are no suspicious circumstances surrounding Mrs Sullivan’s death.

Formal Findings

I formally find that Mrs Sullivan died on 18 March 2007 at the Royal as a result of congestive cardiac failure due to severe calcific disease of the aortic and mitral valves and acute on chronic renal failure.

I accept the opinion of Dr Lawrence that Mrs Sullivan’s condition may have been improved if she had been examined and treated at the Royal when she attended on Wednesday 14 March. However, I note and accept that Mrs Sullivan was suffering severe underlying disease and that her prognosis was poor. In these circumstances I am satisfied that had Mrs Sullivan been properly treated on 14 March then such treatment may have eased her symptoms and made her more comfortable but it would not, in my view, have significantly extended her life.

Comments Specific to the Delay in Treatment

The investigation of the circumstances surrounding this death has highlighted the very serious difficulties encountered by Mrs Sullivan and her family members in accessing medical treatment. This is a matter which, in my view, is of sufficient public interest to warrant comment and this is so notwithstanding my conclusion that Mrs Sullivan’s death would not have been avoided, even if her treatment had been more timely.

It is evident that Mrs Sullivan had difficulty obtaining medical assistance from both general medical practice and from the private hospital sector. However, her greatest difficulty involved accessing the Royal and my consideration of this subject is confined to that institution.

Events on Wednesday 14 March 2007

On this day Mrs Sullivan waited almost nine hours in DEM without being treated and left after being told by medical staff, in effect, that it was not known when she would be seen by a doctor. The Royal, in a joint report provided by its Deputy Director of Medical Services and the Director of Emergency Medicine, attributes the failure to treat Mrs Sullivan on this day to a combination of the following factors:

• 14 March 2007 was the date DEM relocated from its previous facility on Argyle Street to its new premises on Liverpool Street. The joint report states, "While extra medical and nursing staff had been put in place on that day in order to facilitate a smooth transition, there were still many factors leading to slow progress through patients. These included lack of familiarity with the layout of the new Department, encountering and adjusting to new processes for moving patients through from the waiting room into the Department, and revised arrangements for receiving ambulances."
•  The day was an unusually busy one for both DEM and the hospital as a whole. 111 patients were triaged on that day with each patient spending an average of 452 minutes in DEM.
• On that day the hospital was unseasonably full with very limited bed availability. There was one bed on the medical ward, one on oncology, three on the surgical wards and three on the maternity unit. ICU had 12 intubated patients, three over its normal capacity. At 4.00 pm there were four patients requiring admission from DEM that had been allocated beds and were awaiting transfer and a further four patients waiting to be allocated beds.
• 64 other patients came to DEM while Mrs Sullivan was waiting. It was DEM’s practice to categorise patients on arrival. Patients would be allocated to the resuscitation area if critically unwell, to general cubicles if requiring a bed for assessment and management, to a seclusion room if requiring behavioural isolation or rapid control, or to a clinic if suited to rapid "in-out care". Mrs Sullivan was allocated a triage category of 4 and deemed appropriate for the "general cubicle stream". She was placed in a waiting queue only against those other patients suitable for that same stream. There were some patients who arrived at DEM after Mrs Sullivan that were processed ahead of her as they were streamed as suited to either the seclusion rooms or the clinic. (14 for clinic and 3 for seclusion).
•  It was the practice at that time for patients who arrived by ambulance to take precedence over those patients arriving by private transport. This practice was in part to facilitate the early release of ambulances. It meant that patients in the waiting room were often "bumped down the list" by the arrival of ambulance patients, even when the allocated triage category was the same. On 14 March 13 patients arrived by ambulance whilst Mrs Sullivan was in the waiting room.
• As already noted Mrs Sullivan was allocated a triage category of 4. It was hospital policy at the time for any patient who was categorised 1, 2 or 3 to automatically receive a higher priority for access to a cubicle. Because of this patients who may have arrived after Mrs Sullivan were escorted to cubicles before she was. In the time that she was waiting 16 patients arrived who were categorised higher than Mrs Sullivan.
•  At this time it was difficult for senior staff members to maintain an awareness of the situation within the waiting room, "in part due to the aspects of change in facilities, but also in part due to the direct clinical load taken on by the senior medical staff".
• Based on the experiences of other new Emergency Departments elsewhere, it was anticipated that there would be a likely increase in annual patient numbers at the new DEM facility of 5 to 15%. Despite this anticipated increase the only staffing change put in place for the opening of the new facility was to increase staff specialists by 1.5 positions. No provision was made for any additional medical (senior or junior), nursing or allied health personnel to man the new facility.
• In an attempt to cope with an anticipated shortfall in staff, DEM’s management made the decision to open the new facility on a limited basis only in the interests of patient and staff safety. This decision meant that DEM’s custom built 10-bed Short-Stay Unit, a 4-bed "Quiet Adult" area and a 5-bed area dedicated to paediatric care were not opened and available to receive DEM patients.
• The authors of the Royal report advise that even if sufficient staff was available, it is unlikely that the Short Stay facility would have been opened and available for use from the opening day because of "the confusion and stress involved in the move from one facility to another." However, the authors do accept that if sufficient staff had been available both the "Quiet Adult" and paediatric areas could have been utilised from the outset and this would have enabled sufficient patient flow so that Mrs Sullivan would have been examined and treated.

Events on Friday 16 March 2007

As I have noted above Mrs Sullivan elected not to attend at DEM on this day because of advice received from the triage staff that the waiting time was likely to be similar to that experienced on the Wednesday. The Royal has not provided me with any information which indicates this advice to have been incorrect and I thus conclude that those factors which prevented Mrs Sullivan’s timely treatment two days previously were ongoing and would have had a similar impact upon her care had she presented at DEM on the Friday.

Events on Saturday/Sunday 17/18 March 2007

I have already noted that Mrs Sullivan presented at 11.04 pm on Saturday 17 March and was immediately admitted to a cubicle. Within three hours she had been examined by an emergency doctor and a decision had been taken to admit her as an in-patient. However, the admission was not promptly carried out and Mrs Sullivan was still being cared for in a cubicle in DEM when she suffered her cardiac arrest. In my view, no criticism can be made of DEM in its management of Mrs Sullivan over this period save that there was an unreasonable delay in effecting Mrs Sullivan’s admission to the hospital proper.

Changes to DEM post- March 2007

The Royal reports that it has taken the following steps to ameliorate those difficulties which presented at DEM during the first week of its operation in its new facility:-

Concluding Comments

It is abundantly clear that DEM, when it began operating from its new premises on 14 March 2007 was incapable of providing its anticipated patient-load with timely medical attention. Its capacity was so inadequate that triage 4 patients not arriving by ambulance and including Mrs Sullivan, could not be treated at all despite spending a full day in the Department’s waiting room.

I have already found that Mrs Sullivan’s death was not caused by her inability to promptly obtain proper medical treatment. Nevertheless, I am satisfied that had DEM been able to process Mrs Sullivan on Wednesday 14 March then it is highly likely that she would have received treatment, probably as an inpatient, which would have, in the least, modified her symptoms and made her more comfortable over the ensuing days. DEM’s inability to provide Mrs Sullivan with such service was a most regrettable and unsatisfactory state of affairs.

It is apparent that in the period since Mrs Sullivan’s death those shortcomings in DEM which very significantly compromised its capacity to service its patients in a timely manner have been largely addressed. In the result I now accept that those measures which have since been put in place have very largely improved DEM’s capacity to better manage its patient load and reduce waiting times. The likelihood of Mrs Sullivan’s most unfortunate experience being repeated has therefore been markedly reduced.

I conclude by conveying my sincere condolences to the family of Mrs Sullivan.

DATED: Tuesday, 9 June 2009 at Hobart in the State of Tasmania. 

Rod Chandler
CORONER

Note of Amendment: Pages 2 and 5 amended on 16 June 2009 as a result of factual errors relating to the times of Mrs Sullivan’s medical review and death on 18 May 2007.