Multiple failures by Flinders Medical Centre staff contributed to the death of a patient who was administered a lethal dose of pain-killing medication, the South Australian Coroners Court has found.
Stephen Robert Atkins, 53, died suddenly in the hospital in March, 2015 after being admitted to undergo tests for chronic neck pain.
Deputy State Coroner Jayne Basheer found Mr Atkins’ death was caused by fentanyl and oxycodone toxicity — a lethal dose of strong opioid pain-killing medication he had been given in hospital
She found hospital staff failed to properly monitor the dangerous medication regime or escalate Mr Atkins’ care according to clinical protocols.
“The evidence has established that a combination of circumstances, errors and omissions contributed to the death of Mr Atkins,” Ms Basheer said in her findings.
Wife raised concerns with hospital staff
The court heard that Mr Atkins’ wife Lee-Anne had raised concerns with hospital staff prior to his death. (Supplied: Atkins family)
During the inquest, Mr Atkins’ wife Lee-Anne Atkins gave evidence that she had raised her concerns with hospital staff when her husband became groggy, nauseous and was struggling to breathe while on the medication.
“Mrs Atkins tried valiantly to communicate her concerns to a medical doctor and also to several members of the nursing staff. None of her efforts led to a medical review,” Ms Basheer said.
In her 69-page findings, the deputy coroner also said it was inexcusable that staff failed to correctly document their clinical observations.
“There can be no excuse for nurses not to accurately record observations of all vital signs on the RaDAR observation chart. It is a basic task. It requires only diligence and accuracy,” she said.
“The evidence disclosed multiple occasions on which nursing staff failed to escalate care in accordance with the established hospital escalation pathway protocols.
“These failures removed real opportunities for interventions, any one of which could have potentially changed the ultimate outcome for Mr Atkins and his family.”