SA Health investigation into deaths of two stroke patients at RAH amid claims specialists were on leave
SA Health is investigating the deaths of two stroke patients, which occurred when the Royal Adelaide Hospital’s only two specialists qualified to treat them were simultaneously rostered on leave.
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READ BELOW: How the emergency unfolded
SA Health has launched an urgent inquiry into the deaths of two stroke patients, which occurred when the Royal Adelaide Hospital’s only two specialists qualified to give lifesaving treatment were simultaneously rostered on leave.
An internal report shows that as precious minutes passed, a sense of panic was apparent among staff as they realised there was no-one on duty who could treat the first patient because both neurointerventionist radiologists were on holidays.
The only other clinician in the state qualified to give the treatment was contacted and asked to come in to suction a clot from the brain, despite not being employed at the RAH.
The situation was repeated later the same day, and both patients died.
Both cases will be referred to the Coroner.
There were three stroke cases in which the external clinician was asked to help because the RAH’s own specialists were both on holidays — two cases on the same day and one three days later.
In the case involving the first confirmed death, documents obtained by The Advertiser show that when staff realised there was no-one qualified on duty, they contacted one of the specialists who was holidaying on the south coast and alerted him that the patient needed “to have the procedure urgently”.
However, the specialist advised it would be more than three hours before he could get to the RAH to even check the scans let alone perform the delicate procedure to suction the blood clot.
A clinician who was working at another hospital but was rostered on to start at the RAH much later that day was then contacted. However, he said he could not help for another six hours and “had no experience of acute stroke clot retrieval”.
According to SA Health, there are only three people in South Australia that provide this highly specialised treatment. As more time elapsed, staff finally managed to make contact with the third specialist, who agreed to perform the procedure despite not being accredited to work at the RAH.
Almost an hour had elapsed between the patient being admitted and staff making contact with this specialist, who then had to get to the RAH and prepare for the procedure while officials urgently organised the legal paperwork to credential him to work in the hospital.
Consultant Radiologist, Acting Campus Clinical Head, Royal Adelaide Hospital, Dr Jim Buckley released a statement in response to questions from The Advertiser, including whether the delay in treatment was a factor in the patient’s death.
It states: “The patient who presented to the RAH on 18 April requiring specialist clot retraction treatment received treatment in a clinically appropriate time frame.
“The case has been referred to the Coroner which is standard practice when a patient dies as a result of, or within 24 hours of a procedure.”
The statement did not explain what the “clinically appropriate time frame” was, despite it being one of The Advertiser’s questions.
Under the Transforming Health overhaul, the RAH is supposed to be the state’s centre of excellence for stroke treatment, with 24/7 availability of all services.
Flinders Medical Centre in the south and Lyell McEwin Hospital in the north have stroke teams rostered on 8am-8pm seven days a week, but patients needing specialists brain clot removal by suction procedure are supposed to go to the RAH regardless.
Transforming Health documents state: “The plan also defines a clear pathway for patients for Endovascular Clot Retrieval (ECR), with all eligible cases transferred to the RAH.”
A Safety Learning System incident report into the deaths is underway — this is SA Health’s reporting system that investigates adverse events, incidents and near-misses to find the cause and ensure they do not reoccur.
The family of one of the deceased patients was approached by The Advertiser but did not respond to a request for an interview.
Health Minister Jack Snelling and advocates of Transforming Health have repeatedly singled out stroke treatment as a justification for the massive overhaul of the health system.
They cite evidence showing stroke survival rates varied depending on what hospital, and even what time of day, a stroke patient is admitted.
Their solution, under Transforming Health’s mantra of “Best Care. First Time. Every Time.” was to consolidate stroke care in the three major metropolitan hospitals, with the RAH as the flagship for the best care from a qualified specialist supposedly available around the clock.
HOW THE EMERGENCY UNFOLDED:
10.20am, April 18: Stroke patient admitted to RAH, undergoes a series of scans.
10.45am: Decision made that he is suitable for clot retrieval from the brain.
10.47am: Staff realise that the clinician rostered on is not available until 5pm.
10.52am: Staff realise the only two RAH specialists who usually provide such treatment are both on annual leave. Manage to contact one who is holidaying at Victor Harbor and advise him the patient needs ‘to have the procedure urgently’. However, the specialist advises that he would not be able to get to the RAH to view scans until 2pm. Staff explain that they need someone who can provide the service but ‘he was unable to assist me’.
10.54am: Staff manage to contact the clinician who is rostered on to start at 5pm. He is working at another medical centre and advises he cannot come to the RAH until 5pm ‘and had no experience of acute stroke clot retrieval’.
10.55am: Staff contact a senior staff doctor at RAH and tell him of the ‘lack of suitable staff to provide the procedure in RAH’. Urgent discussions are held about what to do.
11.07am: Staff manage to contact the only other specialist in the state who is qualified to do the work. He is not accredited to work at the RAH but agrees to come in to assist the emergency. As he makes his way to the RAH, administration staff prepare the necessary legal paperwork to allow him to perform the procedure at the RAH.
INVESTIGATION:
ADMINISTRATION staff appear surprised at the roster situation and clinical staff ask them to investigate the situation as the roster is the same for the rest of the week. Clinicians ask administrators to ensure that the RAH “as the only neurointevention centre in SA, to support an adequate medical roster until staff return from annual leave”.
THE patient dies within 24 hours of being admitted and the case will be referred to the Coroner.
A SECOND, similar case on the same day results in another call for help to the non-rostered specialist; he is also called in to assist in another case three days later.