SA hospital death preventable: coroner

Coroner David Whittle has recommended changes at Ashford Hospital after a patient's death in 2016.
Coroner David Whittle has recommended changes at Ashford Hospital after a patient's death in 2016.

The death of an Adelaide man who suffered a heart attack in hospital could have been prevented if a medical emergency team had been on hand, a coroner has found.

Hank Jacob Velt died in Ashford Hospital in 2016 while recovering from an operation to remove his gallbladder.

Several days after the procedure, he suffered chest and jaw pain which prompted nurses at the private hospital to perform an ECG.

But he was left alone while the results were faxed to an on-call doctor during which time he experienced ventricular fibrillation and his heart stopped.

In his findings on Friday, coroner David Whittle said he accepted expert evidence during the inquest that had the 65-year-old been seen immediately by a doctor or an emergency team his chances of survival were good.

Mr Whittle said if emergency help was on hand a defibrillator could have been used to revert the cardiac arrest.

Mr Velt could then have been taken to the cardiac catheterisation laboratory and, with a cardiologist on call and a catheter laboratory team he would have had an angiogram and, if required, treatment to re-open blocked arteries.

"All this was on hand at the Ashford Hospital," the coroner said.

Mr Whittle said after earlier opportunities to intervene were missed, Mr Velt was then left alone, ensuring a code blue could not be immediately called when his heart stopped.

He recommended Ashford Hospital change its criteria for calling in a medical emergency team to include any instance where an ECG taken in the absence of a doctor showed indications of a heart attack.

Alternatively, he suggested a doctor be informed immediately if a patient suffered from chest pain and that such patients remain under constant observation until examined.

Australian Associated Press