Coroner’s Report – Robert Webster, Coroner, 1 August 2023
Record of Investigation into Death (Without Inquest) – Anne Pedler
Summary
Mrs Pedler’s presentation at the LGH given the medical history and clinical examination suggested she was suffering from circulatory failure. A presumptive diagnosis of PE, which was correct, was made however the severity of her illness was, as Dr Bell says, ‘underestimated in the extreme’. Immediate treatment by way of thrombolysis or anticoagulation was essential.
That treatment was not provided and Mrs Pedler died. The medical treatment she received was substandard. In addition the ambulance and paramedics were tied up at the hospital thereby making them unavailable for use in other emergencies.
It is reasonable to conclude the standard of medical treatment received by Mrs Pedler was heavily influenced by the fact that not only was there no bed available for her but there was also a lack of nursing staff on duty. In addition there was no CT radiographer available although he or she was not required if the immediate treatment identified by Dr Bell was administered.
While I recognise the THS has conducted a comprehensive RCA and the recommendations, once implemented, will improve system processes they will not overcome what occurred in this case. There were simply too many people requiring medical care from the emergency department at the time of Mrs Pedler’s arrival. It is well known significant pressure is being exerted on emergency departments Australia wide because of resourcing issues and the availability and cost associated with people attending a general practitioner instead.
While I cannot say Mrs Pedler would have survived if she had received appropriate treatment in a timely manner I can say her chances of survival would have been significantly increased had she received the treatment recommended by Dr Bell. Sadly it seems to me until issues associated with the resourcing of emergency departments and access to general practitioners are resolved, by those with the responsibility and power over such issues, cases like this one will continue to occur. I am pessimistic about any progress being made on this front given the 12
RCA and the response from Clinical Associate Professor Atkinson are silent about what THS proposes to do about ramping. If the THS is not looking at ways to resolve this issue then clearly it should be.
The circumstances of Mrs Pedler’s death are not such as to require me to make any further comment or any recommendations pursuant to Section 28 of the Coroners Act 1995.
I convey my sincere condolences to the family and loved ones of Mrs Pedler.
Read the full report here: https://www.magistratescourt.tas.gov.au/__data/assets/pdf_file/0010/716455/Pedler,-Anne-Helen.pdf
Editor’s note: PE = pulmonary embolism, RCA = root cause analysis, THS = Tasmanian Health Service
Media release – Anita Dow MP, Shadow Minister for Health, Mental Health and Wellbeing, 1 August 2023
Tragic death shows our health system is broken
Coroner Robert Webster’s most recent findings into the death of a 70-year-old woman is a damning reflection on the state of Tasmania’s health system.
It is incredibly concerning that yet another coroner’s report has been released about the LGH and highlights that Tasmania’s health system is broken.
Ramping is the worst it has ever been at our hospitals, with ambulances spending 31,000 hours stuck on the ramp between June last year and May this year.
Such is the prevalence of ramping that paramedics are now rostered to the ramp at our major hospitals.
Ramping is symptomatic of a health system in crisis and the desperate need for more beds across our health system.
This most recent and tragic death must be a wake-up call for the minority Liberal Government.
Health Minister Guy Barnett must start listening to the concerns raised by health professionals, properly fund our ambulance service and finally prioritise funding for the $580 million stage 2 redevelopment of the LGH.
He should also consider adopting Labor’s plan to upgrade six ambulance stations around the state, to provide better care in the regions and take pressure off urban services, and our plan to invest in upgrades to Tasmania’s regional hospitals to ease bed block at hospitals like the LGH.
Minister Barnett urgently needs to outline how he will address ambulance ramping and what he will do to ensure deaths like this do not happen again in the future.
Media release – Rosalie Woodruff MP, Greens Leader
— untitled —
Under the Liberals ambulance ramping has spiraled out of control in Tasmania, with information the Greens obtained in Budget Estimates showing patients are being ramped five times more frequently now than they were just seven years ago.
The death of a woman who was ramped at the LGH for a shocking eight hours is just one tragic example of how ramping is leading to an unacceptable risk to the lives and welfare of Tasmanians.
As the Coroner said in his report into this distressing situation, if the Government doesn’t change their approach “cases like this one will continue to occur.”
Greens Leader Rosalie Woodruff MP will today call for the government to immediately commit to a real plan to tackle both the underlying causes and the dangerous effects of the ambulance ramping crisis.
Letter to Stella Jennings – Guiseppe Carra, 2 August 2023
Unsafe Australian Hospitals
Please accept my humblest apology in advance for the intrusion at this time of great grief for your family and my condolences on the unnatural passing of your loved one
However I am emailing you because my family also lost a loved one due to the negligence of a hospital and yet given the evidence that was presented during the Coronial Inquest into their death it was obvious to even the untrained eye that there were a number of systemic OH&S issues at the workplace that contributed to their unnatural death and so subsequent to the Coronial Inquest my family advocated for the death of our loved one to be investigated by the Victorian workplace health and safety regulator WorkSafe
Worksafe Victoria in turn agreed with our family that there were a number of systemic OH&S issues and they subsequerntyly conducted an external, open and transparent investigation into the death of our loved one that occurred at a Victorian hospital under the auspice of the employer Melbourne Health and the Victorian Department of Health
Furthermore WorkSafe subsequently charged the hopsital for 3 breaches of the OH&S Act in regards to the death of our loved one and Melbourne Health were subsequently convicted and fined in the Victorian County Court
For details please see the links below, however be warned the content is very disturbing:
https://www.worksafe.vic.gov.
I am raising this with you because I note that the Tasmanian Coroner has stated in regards to the unnatural death of your loved one that staff shortages at the hospital contributed to their death
And did you know that the failure of a hospital to have sufficient staff to ensure the safety of patients is an OH&S issue
Therefore in consideration of the circumstances surrounding the unnatural death of your loved one and the fact that the Launceston Hospital has been highly criticised by the Tasmanian Coroner in regards to countless unnatural patient deaths it seems to me that there are systemic and widespread OH&S issues at this workplace and it is incumbent on WorkSafe Tasmania to conduct an external, open and transparent investigation to ensure that this is a safe environment and workplace for not only employees but also for people other than employees such as patients
FYI anyone can make a notification to a workplace health and safety regulator in regards to an unsafe workplace and I am happy to assist you in this matter
However mark my words the Tasmanian Coroner will not report this workplace fatality to WorkSafe which seems from my lived experience to be a territorial dispute between these organisation in regards to who is responsible for investigating these types of workplace fatalities
Furthermore as you may not be aware Coronial Findings aren’t legally enforceable so employers are not legally obligated to make any changes to their work practices, policies, procedures or workplaces to prevent a similar incident or fatality which is why unnatural deaths continue to occur at our hospitals despite countless Coronial Inquiries and Findings and the reason why hospitals dont make changes to prevent these deaths subsequent to a Coronial Inquiry – there are no real consequences for the hospital if they do nothing and dont implement any Findings and or recommendations by the Coroner
Just look at the petty dispute between WorkSafe and the Tasmanian Coroner in regards to the sharing of evidence in the Hillcrest disaster and you can see how dysfunctional their relationship is
In addition I can also guarantee you even though the death of your loved one is under the Tasmanian Work health and Safety Act a reportable and notifiable incident the employer has not notified WorkSafe Tasmania of this workplace fatality for someone other than an employee which in itself is a breach of the Act, in what I believe is a deliberate and caculated attempt by the employer to avoid prosecution by the workplace health and safety regulator in regards to a workplace fatality
Therefore if you want justice for your loved one and family than my suggestion is that you immediately notify WorkSafe of this death in light of the evidence presented during the Coronial Inquest and demand that they conduct an external, open and transparent investigation to determine if there have been any breaches of the Work health and Safety Act.
Best regards and good luck in your efforts to obtain justice
