Coroner calls on SA government to make hospitals safer amid ramping death findings

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7 days ago

A South Australian coroner has called on the state government to "formally acknowledge" ramping is "a reality" and focus on making it safer for those who will "inevitably" experience it.
On Thursday, Acting Deputy State Coroner Ian White — who was recently appointed as a judge in South Australia's District Court — handed down his findings following the months-long inquest into the deaths of 76-year-old Anna Vincenza Panella in April 2019, 89-year-old Bernard Anthony Skeffington in September 2021, and 64-year-old Graham Henry Jessett in March 2022.
All three people died after they were ramped at either the Royal Adelaide Hospital (RAH) or Flinders Medical Centre (FMC).
In his published findings, Acting Deputy Coroner White concluded Mr Skeffington's death was preventable and Mr Jessett's was "potentially preventable", but said Mrs Panella's was not.
He said while her "death was not preventable, the circumstances in which it occurred were far less dignified than Mrs Panella deserved".
Acting Deputy Coroner White made a total of 18 recommendations he encouraged the state government to adopt as it continues to address the systemic issues associated with ramping.
"The tragedy lies in being so close to the help needed, but being unable to access it," he wrote.
"In order to commence the process of cultural change and change in the community's attitude to ramping, I make a recommendation directed to the Minister for Health and Wellbeing … that the South Australian government formally acknowledge that ramping is a reality that all modern healthcare systems encounter.
"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."
Acting Deputy State Coroner White said he took into consideration the evidence of all witnesses, including that of the chief executive of SA Health Dr Robyn Lawrence who "agreed that it is reasonable to act on ramping as a reality but also continue to maintain a focus on strategies to end it".
"If that fundamental policy was adopted, the health system can stop pulling itself apart each month as ramping figures roll in," he wrote.
"It can instead focus on doing health the best way it can. The state of South Australia indicated that more recently there has been some level of recognition of this reality."
He also said another key issue explored in the inquest was the understanding of medical professionals as to who "is responsible for the care of patients on the ramp".
"I am not permitted and do not wish to make any findings or suggestions as to liability in respect of the deaths of Mrs Panella, Mr Skeffington and Mr Jessett," he said.
Acting Deputy State Coroner White highlighted that numerous statewide policies should be introduced for the safety of patients including "mandating the use of a structured oral handover between paramedics and triage nurses".
He said another statewide policy should be introduced "requiring visualisation of patients arriving for triage, regardless of their manner of arrival".
Acting Deputy State Coroner White said he hoped his recommendations were adopted by the health system "and improves the manner in which people wait for entry to emergency departments during times of extreme demand".
"In this way, the loss may have meaning for the families in that something positive has developed from the death of their loved ones," he wrote.
"Mrs Panella, Mr Skeffington and Mr Jessett were each important and productive South Australians.
In a written statement, Mr Skeffington's son Martin said he and his family were "very pleased" that his death was "deemed preventable".
"As healthcare workers, we are very aware of the consequences of delays to medical care and realise the problems cannot be fixed overnight and 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," he wrote.
"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 and SA Ambulance Service have been contacted for comment.