Finding into death of Peta Hickey

Contributing factors

• Inappropriate referral for CT coronary angiogram for screening purposes in asymptomatic patient
• Referral lacked clinical indication and adequate patient assessment
• Doctor's signature used without reviewing the patient
• Radiologist proceeded with procedure despite invalid referral
• Failure to recognise anaphylaxis
• Failure to administer intramuscular adrenaline
• Hydrocortisone administered instead of adrenaline
• Pre-medication with beta-blocker (metoprolol) not communicated to paramedics
• Radiologist poorly trained in anaphylaxis management

Coroner's recommendations

1. RANZCR implement mandatory requirement for radiologists to undertake specific training in recognition and management of severe contrast reactions and anaphylaxis every 3 years
2. RANZCR, ASCIA and ARC develop comprehensive training and certification programme for radiologists in anaphylaxis management and CPR/basic life support
3. RANZCR implement register of severe contrast reactions to assess effectiveness of training and compliance with guidelines
4. RANZCR amend contrast reaction management guidelines for display highlighting adrenaline is life-saving and must be used promptly, and role of glucagon in beta-blocked patients
5. RANZCR amend Standard 5.3.2 requiring rejection or return of referrals with no/inadequate clinical information if referring doctor cannot be contacted
6. RANZCR prepare joint position statement with CSANZ regarding when screening is acceptable indicator for CT angiogram
7. RANZCR prepare joint position statements on when screening is acceptable for other imaging procedures
8. RANZCR update standards and guidelines to address increasing prevalence of screening requests and ensure procedures not performed for screening when lower-risk alternatives available
9. MRPB review and update Professional Capabilities for Medical Radiation Practitioners to ensure emergency response adequately addressed
10. MRPB update CPD guidelines requiring all radiographers working with contrast media ensure consistent training in emergency response to severe reactions and anaphylaxis
11. RANZCR, ASCIA, ARC and ASMIRT develop and implement training and certification programme for radiographers in anaphylaxis recognition and management, CPR, basic life support with triannual recertification, including ability to administer adrenaline via autoinjector
12. MRPB, RANZCR and ASMIRT consider expanding radiographers' scope to include preparation and administration of emergency medications
13. FMIG stock adrenaline auto-injectors in addition to vials
14. FMIG revise consent process to include clearly identified consent form for CTCA with specific reference to RANZCR guideline items including radiation risk and alternatives
15. RANZCR update standards regarding radiology practices to ensure adrenaline auto-injectors accessible in every room where contrast administered; policies for responding to inappropriate requests occur promptly; consent procedures include alternatives appropriate to individual circumstances; all radiographers trained in anaphylaxis recognition and management; staff trained and empowered to raise issues in emergencies; onboarding systems for new radiologists include orientation to emergency equipment and assurance of training recency; contrast reaction treatment guideline prominently displayed in all rooms
16. DIAS Advisory Committee review DIAS Practice Accreditation Standards ensuring adrenaline auto-injectors accessible; policies for responding to inappropriate requests occur promptly; consent procedures include alternatives; all radiographers trained in anaphylaxis; staff trained and empowered to raise issues; new radiologist onboarding systems with emergency equipment orientation; contrast reaction treatment guideline displayed
17. RANZCR and DIAS consult each other on distribution of efforts and work together to communicate any changes
18. FMIG review compliance with DIAS Practice Accreditation Standard 2.1
19. Commonwealth Minister for Health audit all Australian accredited diagnostic imaging practices regarding compliance with DIAS Standard 2.1
20. Commonwealth Minister for Health produce and promulgate standard forms for referrals to diagnostic imaging practices with clinical information and contact details, considering whether to mandate use
21. ACCC consider whether enforcement action appropriate against Priority Care Health Solutions, MRI Now regarding unconscionable, misleading and deceptive conduct giving false impressions regarding medical practitioner review
22. RACGP and AFOEM prepare joint position statement on whether practitioners engaged in workplace health have different obligations to 'clients' versus 'patients'
23. RACGP and AFOEM prepare joint position statement on appropriateness of practitioner authorising use of signature in referrals for tests when patient not reviewed
24. Ambulance Victoria issue practice advisory highlighting adrenaline be administered as soon as practicable to patients who acutely deteriorated within short time of receiving radiological contrast
25. Ambulance Victoria issue practice advisory highlighting possibility of beta-blocking medication in anaphylaxis to radiological contrast and consideration of glucagon if unresponsive to adrenaline