Coronial
SAhospital

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Deceased

Anna Vincenza Panella, Bernard Anthony Skeffington, Graham Henry Jessett

Demographics

unknown

Date of death

2019-04-28

Finding date

2025-07-31

Cause of death

Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffington: aspiration pneumonia secondary to small bowel obstruction; Jessett: ischaemic heart disease with cardiomegaly contributed to by hyperkalaemia

AI-generated summary

Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia after waiting 1 hour 43 minutes before admission; Graham Jessett (64) died from ischaemic heart disease complicated by undetected hyperkalaemia. Panella's death was not preventable given her rapid deterioration and atypical presentation, but occurred in undignified circumstances. Skeffington's death was preventable if a nasogastric tube had been inserted before aspiration occurred. Jessett's death was potentially preventable if hyperkalaemia had been identified through blood tests before cardiac arrest. The Inquest examined systemic issues: inadequate patient visualisation at triage, lack of structured handovers, absence of deterioration protocols on ramps, insufficient triage nurse resources, and failure to recognise hospital duty of care for ramped patients. Recommendations focus on improving ramped patient safety through visualisation mandates, structured handovers, deterioration protocols with colour-banded observations, blood testing on ramps, dedicated ambulance waiting areas with better facilities, addressing triage workload, and cultural acceptance that ramping is inevitable in modern healthcare systems.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

emergency medicinecardiologyintensive careparamedicine

Error types

communicationsystemdelay

Clinical conditions

pulmonary thromboembolismdeep vein thrombosisaspiration pneumoniasmall bowel obstructionischaemic heart diseasecardiomegalyhyperkalaemiaarrhythmiarespiratory distressatrial fibrillation

Procedures

triageoxygen therapycardiopulmonary resuscitationintubationnasogastric tube

Contributing factors

  • Delayed transfer of care (ramping)
  • Inadequate patient visualisation at triage
  • Incomplete or missed handover of clinical information
  • Under-appreciation of patient condition at triage
  • Absence of formal deterioration monitoring protocols on ramp
  • Lack of emergency escalation mechanisms on ramp
  • Overcrowding in Emergency Departments
  • Access block and exit block issues
  • Insufficient triage nurse staffing and workload distractions
  • Unclear understanding of hospital duty of care for ramped patients
  • Suboptimal facilities for monitoring patients in ambulances
  • No blood testing on ramp to detect hidden life-threatening conditions

Coroner's recommendations

  1. Acknowledge ramping as inevitable reality in modern healthcare while continuing reduction efforts; shift focus to making ramping safer
  2. Introduce statewide policy requiring visualisation of all patients arriving for triage
  3. Review triage nurse staffing and workload to identify tasks for administrative support during peak demand
  4. Mandate structured oral handovers between paramedics and triage nurses
  5. Require triage nurses to advise paramedics of triage Category assigned
  6. Trial blood samples from ramped patients anticipating wait beyond ATS target with standardised result review process
  7. Introduce statewide policy for managing deteriorating patients on ramp with colour-banded observations and escalation protocols
  8. Construct ambulance waiting areas adjacent to Emergency Departments with dedicated facilities, equipment, emergency buttons, and staffing
  9. Review adequacy of Flinders Medical Centre Emergency Department building and consider relocation
  10. Implement policy clarifying hospital responsibility for care of ramped patients
  11. Roll out status board displays showing system demand across health network
  12. Implement statewide policy on wards accepting patients over census with agreed trigger points
  13. Review approaches to increase weekend and overnight discharges including SWIFT expansion
  14. Review metropolitan LHN structure for possible amalgamation and standardisation
  15. Review mental health catchment areas and resource alignment, particularly for Royal Adelaide Hospital
  16. Explore introduction or expansion of 24-hour transit wards
  17. Mandate clinician involvement in adverse incident reviews on no-fault basis with outcome notification
  18. Review accessibility of ambulance service scripting regarding significant delays

Further listening

Coronial podcast — Episode 94

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