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Coroner calls for hospital admission overhaul following deaths


By John Alati, AMA senior industrial and legal advisor

The admission practices of small private hospitals and the referral of at-risk patients to inadequately resourced facilities have been put under the spotlight following the findings of an inquest into the deaths of two patients in South Australia.

In a case seen to have national implications, the SA Deputy State Coroner Anthony Schapel found that the deaths of two morbidly obese patients – John William Ryan, 54, and Patricia Dawn Walton, 66 – following orthopaedic surgery at a small private hospital in Adelaide highlighted systemic failings in the quality of care they were provided with.

Though the deaths occurred two years apart – Mr Ryan in 2008 and Mrs Walton in 2010 – Mr Schapel said both involved similar circumstances and issues around the admission practices of small private hospitals for higher risk surgical patients.

Both Mr Ryan and Mrs Walton underwent orthopaedic procedures at SportsMed Hospital SA, a small private hospital which did not have medical practitioners in attendance overnight.

Mr Schapel found Mr Ryan’s condition deteriorated during the night immediately following his surgery, while Mrs Walton’s health deteriorated during the fifth night after her operation.

Both were given opioid analgesia, which the Coroner said played a role in their deterioration.

In both cases, the degree of obesity complicated the post-operative management of the patients, as well as hampering resuscitation efforts following their collapse.

In his judgement, Mr Schapel found that both of the deceased posed predictable and continuing risks during the post-operative phase that required a higher level of care than was provided by the hospital concerned. 

The Coroner noted that despite the increasing prevalence of obesity in the community, the link between opioid medication and respiratory depression in this type of post-operative patient appeared to be poorly understood by nursing staff and some medical practitioners. 

Based on the evidence presented to the inquest, Mr Schapel concluded that Mr Ryan’s death could have been avoided if more frequent and adequate monitoring had taken place during the night following his surgery.

It was found that he suffered acute respiratory failure, secondary to a combination of the opiate medication received post-operatively, in the context of his morbid obesity. Had his deterioration been detected in a timely manner, the anaesthetist could have been contacted to formulate a plan which may have involved intravenous administration of naloxone to reverse the effects of the opioid medication. 

Additionally, there is a question as to whether Mr Ryan suffered from undiagnosed sleep apnoea, and how this might have contributed to his respiratory failure. 

In the case of Mrs Walton, who had suffered severe hip pain for some years and had become opioid tolerant, post-operative pain management was always going to be a challenge. She also had hypertension and sleep apnoea, which required a continuous pressure device overnight. 

Throughout the post-operative period her pain and high blood pressure proved difficult to manage. When early signs of cardiac ischaemia emerged during an overnight shift, it was attributed to asthma because the deceased had suffered from the condition in the past. There was no medical officer on site to confirm the diagnosis or to investigate the matter.

The Coroner found that, notwithstanding the unknown cardiac disease, her known medical challenges were such that she should have had her surgery in a hospital which had the medical and nursing resources to handle her complex pain requirements and hypertension. 

Further, this important issue was not appropriately addressed pre-operatively.

Mr Schapel found that to maximise her safety, Mrs Walton should have had her hip surgery in a facility with Intensive Care Unit backup and medical emergency team capability, for early intervention in the event of deterioration. The Coroner found that had she been managed in such an environment, her death may have been prevented. 

Neither patient had the benefit of a pre-anaesthetic consult. As a consequence, the anaesthetists had to deal with the situation under pressure, moments before surgery.

In both cases, the surgery was completed without incident, but the problems arose in the post-operative phase.

Both patients were evacuated to Royal Adelaide Hospital by ambulance when they collapsed, but passed away in the ICU once testing confirmed that irreversible hypoxic cerebral damage had occurred. 

In delivering his findings, Mr Schapel made a number of detailed recommendations aimed at reducing the likelihood of more deaths in circumstances similar to those that claimed the lives of Mr Ryan and Mrs Walton.

His recommendations, which have been directed to a range of health related bodies, including the AMA, included:

  • that small private hospitals develop robust pre-admission processes in which higher risk patients are screened to ensure that they are not accepted for overnight admission unless they have been assessed as suitable for that facility by a medical specialist or anaesthetist, well in advance of the planned admission date;

·        heightened awareness amongst medical practitioners and nurses about the inherent risks of post-operative respiratory depression occurring in obese patients who may or may not have a diagnosis of sleep apnoea and who are receiving or have received opioid analgesia;

·        that the Medical Board of Australia consider formulating a code of conduct which stipulates that medical practitioners who practice preferentially in a facility in which they have a financial interest, should disclose that fact to the patient appropriately and specifically raise the issue concerning suitability of that facility with other specialists to whom they refer the patient for pre-admission assessment;

·        that the process by which higher risk patients are referred for pre-anaesthetic assessment be streamlined; and

·        that last minute changes to operating lists which would result in a different anaesthetist taking over immediately before surgery be avoided.

The full decision can be found on the South Australian Coroner’s website at