South Australia's State Coroner David Whittle has found that Petar Josipovic, 62, would likely have survived had his category one cardiac surgery been performed on or before August 22, 2023, but that 'the opportunity to perform it earlier did not genuinely arise' because of systemic pressures on an overworked health system, according to findings handed down at the Coroners Court.
South Australia coroner finds cardiac patient's death linked to systemic overwork, surgery delayed beyond 30-day category one limit
South Australia's State Coroner David Whittle has found that Petar Josipovic, 62, would likely have survived had his category one cardiac surgery been performed on or before August 22, 2023, but that 'the opportunity to perform it earlier did not genuinely arise' because of systemic pressures on an overworked health system, according to findings handed down at the Coroners Court.
Josipovic was placed on a waiting list for category one cardiac surgery at the Royal Adelaide Hospital (RAH) in June 2023. Category one surgery should occur within 30 days. His operation was instead scheduled for August 14, 2023 — 54 days later — and was subsequently rescheduled multiple times.
He became unwell on August 24, 2023, and was taken to hospital, where he suffered a cardiac arrest. Emergency surgery was performed successfully the following morning, but he died from complications three weeks later, on September 14, 2023.
Whittle found that, on the balance of probabilities, Josipovic's death 'would have been unlikely if surgery was performed' on or before August 22, 2023. He said, however, that proceeding with surgery on August 14 'might have come at the cost of the chance of survival of another patient' given the wider demands on the system at the time, and that 'difficult decisions were made'.
The coroner said he was 'impressed with the witnesses who gave evidence' and did 'not make any finding that decisions that led to the cancellations were the result of ill-will or lack of due care'. He noted there was 'a wider cohort of concerning patients' at the time.
Whittle also noted that Josipovic did not attend the emergency department on earlier occasions when he was invited to do so, which the coroner said would 'reasonably give clinicians a sense of ease about the seriousness of his deterioration' and also prevented a physical examination that was 'necessary to fully appreciate his risk'.
The inquest heard that elective surgery would have cost less than $75,000, while the ultimate cost of care following his emergency admission was $250,000. Whittle said the delay 'exponentially increased the risk to his life and the financial cost to the state'.
Whittle noted several improvements to cardiothoracic services at the RAH since Josipovic's death, including increased operating capacity and 'better oversight of waiting lists', but said 'more can be done'.
The coroner made two recommendations to Health Minister Blair Boyer: that an external review be conducted covering the referral process, clinic capacity, the costs and benefits of an additional theatre list, and surgical cancellations; and that clear guidelines be developed on the information and advice to be given to patients awaiting cardiothoracic surgery who report clinical deterioration.
Whittle expressed condolences to the Josipovic family, noting that Josipovic's son Nick had attended the hearing each day and given evidence.
- The Health Minister Blair Boyer's response to the coroner's recommendations is not reported.
- The Royal Adelaide Hospital's or SA Health's formal response to the findings is not reported.
- The specific reasons each individual surgical cancellation was made are not detailed.
- The identity or outcome of the other patients referenced as competing for theatre time is not disclosed.
- Whether the external review recommended by the coroner has been initiated is not stated.
Read the original at ABC News Australia