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Coroner slams SA Health for "compromising" stroke deaths evidence

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The State Coroner says SA Health employees compromised evidence and damaged the possibility of an inquest into the deaths of two stroke patients last month by failing to report the cases adequately.

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Coroner Mark Johns released a statement this morning saying he may not call an inquest because it is now too late for an autopsy into the deaths, which occurred while two specialist doctors who may have been able to provide treatment were both rostered on leave.

Johns says he would have likely ordered an autopsy if the medical officer who reported one of the deaths had included that key detail.

He says no report concerning the second of the two deaths was made to his office – instead, he had to request information about the case from SA Health after it was reported in the media.

“The Coroner warns that it may not be possible for a coronial inquiry to determine whether the unavailability of the neurointerventionists contributed to the deaths of either of the patients at the Royal Adelaide Hospital last month, and so he may not decide to have an inquest into these cases,” a spokesperson for the Coroner said in a statement released today.

“… There was nothing about the report [concerning the first death] which would have alerted the Coroner to the possibility that the unavailability of neurointerventionist radiologists was a possible matter of concern in the circumstances of the patient’s death.

“Had the Coroner been aware of that information when the death was reported, it is likely that he would have directed an autopsy.

“It is now too late for that.”

Evidence concerning the deaths was now compromised.

“Furthermore, [Johns] may have directed that police take statements at an early time to prevent loss of evidence, as memories fade,” the statement said.

“That opportunity has now been compromised.

“It is misleading to allow the public to think that it was reported in a manner that would enable the Coroner to investigate effectively the issues that are now emerging.”

Johns said the report into the first death appears to have been made by a junior medical officer with little or no connection to the case.

“… the Coroner has repeatedly, over many years, expressed concerns to SA Health about the practice of medical reports of death being prepared by junior medical officers who had little or nothing to do with the patient’s care,” the spokesperson said.

“That practice results in a lack of transparency, and the present situation appears to be another example of this.”

SA Health told InDaily this afternoon: “Under the Coroners Act, it’s the obligation of a medical practitioner reporting a death to the Coroner to provide his or her opinion of the cause of death.”

“It is not for SA Health to intervene in their clinical opinion.

“We’ll continue to work with the Coroner’s Office about the information they require in cases such as these going forward.”

Johns also said his staff had searched his office last Saturday morning – the day a report into the deaths was published in The Advertiser.

“However, the Coroner’s Office did not have the patients’ names, and the cases could not be identified,” the statement says.

“On Monday morning […Johns] contacted the chief executive of SA Health [Vickie Kaminski] to ask for the names of the patients involved.

“That information was not provided until 1.30pm.”

He said SA Health may not report the second death to his office, but that decision was being reviewed at Kaminski’s request.

“The Coroner has issued a direction to the RAH to provide the case notes for the second patient, and it is expected they will be received today.

“Again, this is a case in which it is almost certainly now too late to direct an autopsy, and to pursue other initial lines of inquiry.”

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