Beachport man’s death exposed flaws in South Australian medical system, coroner finds

Beachport man’s death exposed flaws in South Australian medical system, coroner finds

ABC South East SA


A South Australian coroner has made a string of recommendations to health providers after the death of an elderly Beachport man from legionella-caused pneumonia.

Edward Mayell went to his Beachport GP in September 2014, complaining of lethargy, loss of appetite and weight loss.

The 83-year-old returned to his doctor on two more occasions, before being transferred to Millicent Hospital, Mount Gambier Hospital and later the Flinders Medical Centre in Adelaide, where he died on October 5, 2014.

The findings of an inquest handed down by deputy state coroner Anthony Schapel found Mr Mayell’s death was from natural causes, but also found that urgent medical information had not been shared between the multiple service providers and practitioners who had treated Mr Mayell.

Eight recommendations will be brought to the attention of local, state and national medical service providers and entities following the coroner’s report.

Mr Schapel’s report found Millicent Hospital’s treatment and management of Mr Mayell on the afternoon of September 17 — his second attendance at the facility — was “sub-optimal”.

The report stated that administration of antibiotics at the facility was “unduly delayed” and was inadequate for the type of pneumonia — community acquired pneumonia from typical or atypical organisms — Mr Mayell was suffering from.

However, the coroner did state that had the appropriate antibiotic therapy been started earlier, it may not have prevented Mr Mayell’s death.


Timeline examined


The timeline of Mr Mayell’s developing illness and the transmission of vital medical information between practitioners and services was closely examined during the inquest, which took in evidence from Mount Gambier and Adelaide.

Mr Schapel said SA Health, Country Health SA and the South Australian Ambulance Service needed to come to a clear and mutual understanding over the appropriate hospital a patient in the state’s south-east should be transferred to.

It was also recommended that the Beachport Medical Centre should have clearer communication with the Millicent and Mount Gambier Hospitals regarding the transmission of important patient information

Benson Radiology, where Mr Mayell received a chest X-ray on September 16, was the subject of another recommendation, urged to remind staff that unexpected and urgent radiological findings were to be immediately relayed to the referring medical practitioner.

One of the recommendations included that SA Health consider running a statewide project involving nurses and medical practitioners regarding sepsis identification and treatment.

The coroner also recommended the Picture Archival Communications System (PACS) be immediately installed at the Millicent Hospital, so that radiological imaging could be electronically shared to the facility by radiology service providers.


Recommendations should be adopted: AMA


The Australian Medical Association (AMA) said in light of the findings, it was important that SA Health and Country Health SA reviewed the procedures currently in place.

AMA South Australian president Janice Fletcher said she would be disappointed if the recommendations in the coroner’s report were not widely adopted.

“I think it’s the coroner’s fear that situations like this should happen again,” she said.

“Mr Schapel is trying to put in place as many recommendations as he feels necessary to reduce the likelihood of incidents happening again.”

The AMA said Country Health SA and local communities needed to agree on what health services were delivered in regional communities.

Dr Fletcher said her organisation had been asking Country Health SA to answer what the capacity of each regional hospital was for the past two years.

She said the AMA accepted there was less availability of specialists in small country towns, but people needed to know where to go when they required urgent medical services.

A spokesperson from SA Health said the organisation was reviewing the coroner’s findings and recommendations.

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