Readers of this blog may remember the findings of an inquest by the South Australian Coroner into the death of Marjorie Irene Aston on 17 July 2015 included reference to a risk arising from the use of ordinary post to report to a general practitioner.
Dr Cristina Pelkas has kindly pointed out the similar issue which arose in a more recent South Australian coronial decision, the inquest regarding the death of Jordan Zerk. Cardiac test results had been sent by post to the Royal Children’s Hospital in Melbourne, but did not reach the hospital (or at least did not reach the cardiac surgery team) such that advice was not given about the need for surgery. A letter sent some 12 months earlier had also not reached the patient’s file.
The coroner commented adversely on reliance on the “ordinary mail service” at [8.3]:
The health system is South Australia consumes billions of dollars, and at a national
level, billions more. In a system that vast, it is absurd and unacceptable that the life of an otherwise healthy 15 year old should be put at risk by reliance upon the ordinary mail service. There is no paediatric cardiac surgery service in Adelaide. Therefore it is necessary to send information to the services in Melbourne. There must be a fail-safe mechanism for that to happen, whether the patient is a public patient at the Women’s and Children’s Hospital, or a private patient of a cardiologist such as Dr Adams.
I recommend a mandatory system be instituted for all cardiologists treating paediatric patients, under which they must register the patient with the Women’s and Children’s Hospital, and the patients data must be provided to the Women’s and Children’s Hospital as and when it is gathered. The Women’s and Children’s Hospital should then be responsible for forwarding the reports to the team in Melbourne when that is required. Short of recommending that a paediatric cardiac surgical service be commenced in Adelaide, nothing less than the supervision of the safe transmission of crucial data by the Women’s and Children’s Hospital can suffice.