A review into the death of a woman who waited three hours for treatment at a WA country hospital has found there were delays in her treatment amid "unprecedented" demand, but that it was "unlikely" she could have been saved if she had been seen immediately.
The woman, aged in her 70s, was taken to Busselton Health Campus on April 19, where she died while still in the care of paramedics after her move into the emergency department had been delayed.
WA Health Minister Amber-Jade Sanderson said the review found the woman's cause of death was the result of a "rare and life-threatening" condition, specifically the rupture of a dissecting thoracic aortic aneurysm – a tear in the heart's main artery.
Ms Sanderson said the review had found it was "unlikely" her death could have been prevented if she had been handed over to the emergency department immediately.
She said the woman had been taken to hospital after complaining of lower back pain and had been able to walk around while she waited, before her condition deteriorated rapidly.
"This was unprecedented and could not have been predicted," she said.
"Even if [she] had gone through quicker and been seen quicker it is unlikely that the outcome would have been different."
However, Ms Sanderson said the review also found the woman should have been seen sooner.
The woman waited hours for treatment by hospital staff despite being triaged as "urgent", which is supposed to have a maximum waiting time of 30 minutes.
“We do know that the patient did wait longer than they should have to be moved to a cubicle and undergo a full medical assessment,” she said.
“On the 19th of April, the emergency department was well staffed, however the staffing compliment was not enough to manage the increasing workload on that day.”
Ambulance presentations doubled
Ms Sanderson said the busy emergency department was a key factor in delays to the woman's treatment, with almost double the normal number of ambulance presentations on that day.
Paramedics had not been able to hand the woman over to hospital staff, which falls under the definition of ambulance ramping.
The issue has worsened in recent weeks due to staff being off sick from COVID and elevated demand for ambulances, which twice prompted St John WA to warn of delays.
Last month, WA Premier Mark McGowan apologised to the family of Georgina Wild who died while waiting more than two hours for an ambulance.
In April, a Geraldton woman died waiting for an ambulance.
Ms Sanderson said the review into the woman's death in Busselton death found there was also a "much higher than usual" number of "complex cases" presenting on the day.
She said the independent review panel, which consisted of seven health care experts, included the interim report from the coroner and the advice from a senior cardio-thoracic surgeon.
Recommendations to be adopted
The review made several recommendations, which Ms Sanderson said would be implemented as soon as it is practical.
"We would like to avoid this happening ever again and I would like to extend my deepest sympathies again to the patient's family," she said.
At Busselton Health Campus, these include:
- Establishing an emergency department coordinator during the day
- A rostered nurse to oversee patients waiting to be seen.
Improvements at the WA Country Health Service [WACHS] include:
- Action to ensure all patients in the care of ambulance staff are reviewed and monitored by hospital staff
- A new plan aimed at supporting country emergency departments during busy periods
- Raising awareness of dissecting thoracic aortic aneurysms among ED clinicians.
St John Ambulance WA will be required to notify WACHS in real time when ambulance ramping occurs to ensure patients are being moved through ED.
Health system under 'extraordinary pressure'
Opposition health spokeswoman Libby Mettam welcomed increased staffing and resources to the hospital, but said it was disappointing it took a death to get support for the regional hospital.
"It is always a very busy emergency department, particularly during the holiday period," she said.
"This is a tragic incident and it's disappointing it's taken an incident to ensure there are additional staffing resources at Busselton hospital.
"It points to a health system that is under extraordinary pressure.
"Our heart goes out to the family and the health workers and ambulance crew who are all doing their best."
