Inquest findings into ramping deaths of Anna Panella, Bernard Skeffington and Graham Jessett released

A Coroner investigating the deaths of three ramped Adelaide patients has delivered damning findings into the state of SA’s healthcare system.

Ramping is an entrenched issue in South Australia’s health system, and should be accepted as an “inevitable experience” rather than an entirely fixable problem, the Coroner’s Court has found.

An inquest into three patients who died suffering medical complications after an extended period of ramping ruled one – the death of Bernard ‘Brian’ Anthony Skeffington, 89 – was preventable.

Former Deputy State Coroner Ian White, now a District Court Judge, also found hospital staff were undermined by “systemic issues” during the three deaths, which occurred between April 2019 and March 2022.

On Thursday, Mr White also ruled the death of Graham Henry Jessett, 64 was likely “not preventable”, but delays and misclassification limited his care options.

He found the death of Anna Vincenza Panella, 76, was “not preventable” due to her deterioration, but that death was “far less dignified than she deserved”.

“The tragedy lies in being so close to the help needed, but being unable to access it,“ Mr White said about Mr Skeffington.

“I consider that the scenario of Mr Skeffington being taken into the department, assessed and having a nasogastric tube inserted prior to his aspiration event is not a theoretical possibility, it is a scenario that was open and, if occurred, would likely have prevented his death.”

He recommended the Health Minister and state government “formally acknowledge” ramping is a reality “all modern healthcare systems encounter”.

Bernard "Brian" Skeffington. Picture: Supplied

“While efforts to reduce the levels of ramping remain extremely important, efforts must also be made to make the process of ramping safer for those patients who will inevitably experience it.

“It is clear that the road to reducing and indeed trying to eliminate ramping is going to be a long one.

“It is going to be paved with initiatives which are novel, initiatives which fail and hopefully initiatives which each individually contribute in a small way to the overall goal.”

Mr Skeffington was taken to the Royal Adelaide Hospital on September 25, 2021, after waiting three hours and 42 minutes after calling triple-0.

He was later taken to comfort care where he died on September 29, 2021, as a result of aspiration pneumonia secondary to small bowel obstruction.

Graham Jessett. Picture: Provided by family

Anna Vincenza Panella. Picture: Supplied

The inquest previously heard Mr Jessett, who was a type 1 diabetic and suffering from chronic pulmonary obstructive disease, was “ramped” for five hours – before he collapsed onto his hospital bed and went into cardiac arrest.

CPR was commenced “immediately” but Mr Jessett was pronounced dead at 6pm, after a decision was made to stop resuscitation.

Outside court, Mr Skeffington’s family said they understood the “consequences of delays” and “realise the problems cannot be fixed overnight”.

“It involves many moving parts involving emergency departments, hospital beds and staffing which are all in need of an overhaul to fix the many problems,” they said.

“As a family, we thank the SA Ambulance staff who attended to Brian on that awful day and tried their very best in difficult circumstances.

“We wish not to blame any single person but hope that this inquest will bring about positive change so no other families have to go through this ordeal.”

SA Health CEO Dr Robyn Lawrence said the Coroner’s findings highlighted SA Health was a “leader in several areas combating ramping” and that they represent an excellent use of public funds.

She expressed condolences for the families.

Originally published as Inquest findings into ramping deaths of Anna Panella, Bernard Skeffington and Graham Jessett released