Coroner's Finding: RYAN John William and WALTON Patricia Dawn

Contributing factors

• Morbid obesity in both patients
• Opioid-induced respiratory depression (Ryan)
• Inadequate post-operative monitoring
• Lack of medical practitioners on-site overnight
• No ICU/HDU backup at hospital
• Inadequate pre-operative anaesthetic assessment
• Flawed pre-admission screening processes
• Undertrained and understaffed nursing
• Failure to detect early signs of deterioration
• IV line removal without medical consultation (Ryan)
• Misdiagnosis of cardiac symptoms as asthma (Walton)
• Uncontrolled hypertension and poor pain control (Walton)
• Undiagnosed sleep apnoea
• Undiagnosed triple vessel coronary artery disease (Walton)
• Possible undiagnosed sleep apnoea (Ryan)

Coroner's recommendations

1. Minister for Health, ACSQHC and ACHS require small private hospitals without on-site medical overnight cover to develop robust pre-admission screening by medical specialists/anaesthetists for higher-risk patients
2. Medical Board of Australia, AMA, AMC, ACN and nursing schools raise awareness of risks of post-operative respiratory depression in obese patients receiving opioid analgesia, with or without sleep apnoea diagnosis
3. Medical Board of Australia formulate code of conduct requiring practitioners with financial interests in facilities to disclose appropriately to patients and specifically raise facility suitability with referred specialists
4. ANZCA South Australia, RACS South Australia and Australian Society of Orthopaedic Surgeons streamline pre-anaesthetic assessment processes and avoid last-minute operating list changes
5. Hospital boards and CEOs of small private hospitals decline admission of higher-risk patients where facilities/staffing are inadequate