Busselton Health Campus death: Report finds elderly woman died while waiting for care from rare aneurysm

A report into the death of an elderly woman at Busselton Health Campus in April has found she died of a rare aneurysm — and the tragic fatal outcome would likely have been the same regardless of her extended wait for treatment. Delivering the clinical incident investigation report on Tuesday, WA Health Minister Amber-Jade Sanderson said the regional hospital had been experiencing record presentations with increased high-urgency patients when the woman was admitted. New details of her presentation on April 19 revealed the local woman had suffered from a rare life-threatening rupture of a dissecting thoracic aortic aneurysm — a tear in the main artery of her heart that caused internal bleeding. The woman was triaged “urgent” upon arrival — which carries a maximum waiting time of 30 minutes — but had not been treated until hours later when she rapidly deteriorated and died of a suspected heart attack. The woman attended the ED after suffering from back pain and had been able to walk around as she waited. Ms Sanderson said hospital staff had, at the time, been dealing with almost double the average ambulance presentations that day. More than 16 ambulances had brought patients to the ED — a dramatic jump from the hospital’s average of eight. Presentations also had more acute needs, with a 40 per cent spike of “high-urgency” patients. “The review has been undertaken by seven experienced healthcare professionals, including some independent in WA Country Health,” Ms Sanderson said. “These experts were selected in line with internationally recognized best practice guidelines. “They considered the coroner’s interim findings and expert opinion from a senior cardiothoracic surgeon and concluded that this patient’s death was a result of a rare and life-threatening condition and rupture of a dissecting thoracic aortic aneurysm. “The panel noted the outcome was unlikely to have been different even if the patient had been seen immediately because this kind of aneurysm is so serious. “Overall, there are less than 40 cases across Australia each year.” Ms Sanderson on Friday said the Department’s investigation had concluded and its findings were disclosed in full to the grieving family across the weekend. She had spoken with the family on Monday. Ms Sanderson said her heart went out to the family of the woman, aged in her 70s. “Their wellbeing remains front of mind for us. While we know that nothing can replace their loss, it was important that we undertook a thorough and detailed investigation,” Ms Sanderson said. The key recommendations of the review include establishing an ED nurse coordinator to triage patients, ensuring St John WA provides real-time ramping data to WA Country Health Service and ambulance patients are monitored by hospital staff similarly to those in ED. WA Country Health Service has also been encouraged to look at other options in high-demand times, including emergency telehealth and diverting patients to other hospitals. WACHS chief executive Jeffrey Moffet said the condition was rare and required vascular surgery. “The reality is a rupture of an aneurysm is a life-threatening condition and it’s very difficult to change the outcome in a hospital setting generally,” he said. The Busselton woman’s death came on the same day as that of much-loved Geraldton great-grandmother Joan Hope, who died of a heart attack while waiting more than half an hour for an ambulance to arrive. She had been driving around town earlier in the day when she began having trouble breathing and pulled up outside her son Jason’s house. With his mother clearly in respiratory distress, Jason rang 000 shortly before 2.30pm and then endured an agonising wait for paramedics, the first of whom did not arrive at the scene until just over 30 minutes later. For 20 of those minutes Mrs Hope was conscious and struggling for breath before she rapidly deteriorated and suffered a suspected heart attack. After Mrs Hope passed out Jason was directed to drag her out of the vehicle and perform CPR, which he did for 10 minutes before paramedics arrived — by which time it was too late to save her.