The death of a young woman with meningococcal disease was found to have been “accelerated” by Royal Perth Hospital, which offered her “below standard” care, a coroner has found.
Geraldton woman Ashleigh Hunter, 26, drove to Perth from Geraldton to meet her partner for the Christmas holidays. They had rented an Airbnb apartment in East Perth.
But she woke up two days after Christmas Day in 2019, believing she had a cold — but when her condition began to rapidly deteriorate, she was rushed to the Royal Perth Hospital emergency department, which was brimming at capacity.
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The inquest into her death found that Hunter waited 13 minutes to be triaged, and spent up to 29 minutes being monitored in an ambulance on the hospital ramp after she arrived at 1.16pm that day.
She was assessed by a doctor about an hour after she arrived at the hospital, and inquest findings reported her deterioration was consistent with meningococcal sepsis.
She went into cardiac arrest shortly after and was unable to be revived.
“While it could not be established that the delay in Ashleigh’s treatment contributed to her death, it most likely affected the time of her death by bringing it forward,” the coronial inquest findings delivered on December 13, 2023 said.
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Hunter was hospital patient number 124 of 259 for that day, more than 50 patients higher than the daily average treated at Royal Perth Hospital.
Triage notes describe Hunter’s self-described pain score as a 10 out of 10, but the nurse observing Hunter believed a more accurate score was seven out of 10 as she was able to be “distracted” from her pain.
She was triaged under the triage code of three, which meant she was eligible to remain outside the hospital. Had she been triaged under triage code of two, she would have been assessed by a doctor in the emergency department within 10 minutes.
State Coroner Ros Fogliani said that she did not criticise the nurse’s triage error, but noted the “limits of the systems and procedures available to her” which were further addressed in the eight recommendations Fogliani handed down.
“There were missed opportunities to identify the seriousness of Ashleigh’s condition earlier, and that the quality of care and treatment afforded to Ashleigh was below the standard that ought to be expected of a public hospital in Western Australia,” the report said.
Ashleigh Hunter died of a cardiac arrest with meningococcal disease at Royal Perth Hospital, two days after Christmas in 2019. Credit: FacebookA coroner found that the public hospital missed opportunities to prolong Hunter’s life during an inquiry into her death. Credit: AAP
Fogliani also found that while Hunter wasn’t a regular drug user, she had taken illicit drugs the night before her death — and while drugs didn’t cause her death, her admission of drug use may have impacted her treatment.
The nurse admitted during the inquiry: “If there was no drugs on board, yes, I would have said this looks like sepsis.”
The inquiry looked into whether the cause of Hunter’s symptoms was “clouded” by a cognitive bias regarding the illicit drug use.
While Fogliani found no such inappropriate culture was prevalent, she said: “In hindsight, the focus on the illicit drugs was not warranted.”
A lack of pain management, the “fragmentation of care” as Hunter passed through various areas of the hospital, and the overcrowding of the emergency department were also investigated.
Though Hunter’s death was unable to be deemed entirely preventable, and Fogliani was mindful of hindsight bias, she said the acceleration of the death was devastating for loved ones.
“Her prospects of survival, with prompt medical treatment, while very slim, were not wholly absent,” Fogliani said.
“The coroner regards the loss of an opportunity to survive as a serious matter.”
“Ashleigh’s family have had to grapple with the thought that prompt treatment may have at least extended Ashleigh’s life for long enough to allow her loved ones to travel to Royal Perth Hospital to say goodbye,” Fogliani said.
“No doubt the loss of that possibility is devastating to those who loved Ashleigh.”
Fogliani recommended better access to electronic medical records, improved pathways for sharing information between ambulance and hospital staff, a working definition of “emergency”, clinical training for unusual presentations of sepsis, and a public awareness campaign for meningococcal vaccines.