SA Coroner told RAH stroke patient Leslie Robert Graham had to wait three times as long as expected for emergency treatment
A SERIOUSLY ill stroke patient’s emergency treatment was delayed almost three times as long as the expected wait due to the Royal Adelaide Hospital specialist rostering bungle, an inquest has heard.
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A STROKE patient had to wait almost three times as long to undergo an emergency procedure at the Royal Adelaide Hospital when a roster bungle meant no specialist was readily available, an inquest has heard.
On Tuesday, RAH angio-secretary Debra Matthews told State Coroner Mark Johns that the atmosphere in the angio-suite when staff were trying to find an Interventional Neuro-Radiology (INR) specialist was “surreal”.
“It was a bit surreal that this was how it was playing out,” she said.
Mr Johns is holding an urgent inquest into the deaths of RAH stroke patients Michael John Russell and Leslie Robert Graham, who died when the hospital’s only two INR specialists were on leave at the same time.
Dr James Taylor and Dr Rebecca Scroop were both on leave in April and were unavailable to do the procedures.
Ms Matthews said in her experience, a clot retrieval would generally take up to 30 minutes to co-ordinate, including calling in either Dr Taylor and Dr Scroop.
But the inquest has previously heard Mr Graham was deemed a suitable candidate for the procedure at 10.40am on April 18.
By the time another INR specialist, Dr Steve Chryssidis, arrived at the RAH and had been given the accreditation to perform the procedure, it was 12.05pm — one hour and 25 minutes later.
But RAH stroke consultant Dr Janakan Ravindran told the inquest there wasn’t much of a delay.
“(Dr Chryssidis) came in very quickly and in many ways that was virtuous,” he said.
“If you look at the whole thing, I don’t think there was much of a delay.
“It was well within the time frame — I wouldn’t say it was acceptable but it was within the time frame.”
He said the median time for the procedure was 40 minutes at the RAH.
On Monday, RAH stroke resident medical officer, Dr Jane Thompson, told the court that not having either senior INR specialist on duty had created a “scary” patient scenario.
Asked by counsel assisting the coroner, Naomi Kereru, how she felt and how she was “coping” knowing there were no specialists readily available, Dr Thompson replied: “It was scary.”
“To have a patient in front of you who was awaiting an emergency procedure and not knowing whether you are going to have someone able to perform that (operation),” she said.
“I have not been in that situation.”
The hospital’s stroke unit nurse Carole Hampton told the inquest it was “unusual” having the specialists both on leave.
Ms Hampton said she made an internal complaint to SA Health via the online Safety Learning System because it was a “serious” incident not to have adequate INR coverage.
She categorised the complaint at the highest level, meaning it was going to be automatically investigated.
The court has heard Dr Scroop was flying to America while Dr Taylor was three hours away on a fishing holiday near Victor Harbor despite being “on call” and able to “scrub in” at short notice.
Their boss, Dr Jim Buckley, last week told the inquest the rostering blunder was an “error” while Mr Johns has questioned the hospital’s “casual” approach to health administration.
An internal SA Health review found there had been “longstanding, territorial” issues between the three stroke specialists employed by SA Medical Imaging — Dr Taylor, Dr Scroop and Dr Chryssidis.
The court has heard the RAH specialists who covered a 24-hour roster may have been resisting assistance to “protect their patch” because they were earning more than $1.1 million a year.
Mr Graham’s death on April 26 was only formally reported almost three weeks later — only after it was revealed by The Advertiser — which also meant no post-mortem examination was completed.
While Mr Russell’s death on April 21 was reported to the coroner, no mention was made of “staffing issues” so no autopsy was undertaken, the inquest has heard. It was now too late for such procedures.
Dr Taylor, Dr Scroop and Dr Chryssidis will give evidence later.
The inquest continues.