A grandmother who died after waiting almost eight hours for a bed at a Tasmanian hospital received substandard treatment and her illness was underestimated in the extreme, according to a coroner's report.
Anne Helen Pedler, 71, arrived at the Launceston General Hospital in an ambulance at 12.45pm on August 6, 2022 suffering shortness of breath, nausea and vomiting.
Hospital staff gave a likely diagnosis of a pulmonary embolism, her eventual cause of death, and requested a CT scan which was ultimately not performed.
About 8.30am, while awaiting an emergency department bed and under the care of Ambulance Tasmania, Ms Pedler suffered a cardiac arrest and died.
"Immediate treatment by way of thrombolysis or anticoagulation was essential," coroner Robert Webster wrote in findings published on Tuesday.
"That treatment was not provided and Mrs Pedler died. The medical treatment she received was substandard.
"In addition, the ambulance and paramedics were tied up at the hospital thereby making them unavailable for use in other emergencies."
Dr Anthony Bell, a coronial medical consultant who reviewed Mrs Pedler's case, said the severity of her illness was "underestimated in the extreme".
"No viable plan was formulated, there was no consideration of treatment before a definite diagnosis," Dr Bell wrote.
"The management of the patient was below acceptable standard of care."
Mr Webster said Mrs Pedler's chances of survival would have "significantly increased" had she received treatment recommended in Dr Bell's review.
Mr Webster noted the Tasmanian Health Service had undertaken a root-cause analysis of Mrs Pedler's death and hospital processes would improve once recommendations were implemented.
"(However) they will not overcome what occurred in this case," he said.
"There were simply too many people requiring medical care from the emergency department at the time of Mrs Pedler’s arrival."
He said until issues with emergency department staffing and access to general practitioners were resolved, cases like Mrs Pedler's would continue to occur.
Mr Webster said the root-cause analysis and a response from a Tasmanian Health Service executive director were "silent" on what was being done about ramping.
Ramping occurs when someone is taken to hospital by ambulance but cannot be admitted to the emergency department because it is full.
According to the root-cause analysis, there was a significant delay in ordering an urgent CT scan for Mrs Pedler because there was a wait for blood tests to be returned.
The pathology request was marked urgent and bloods sent for analysis but a follow-up phone call alerting the on-call pathologist to the urgency of the results didn't occur.
The analysis also identified the hospital doesn't have a 24-hour radiology service and new medical staff don't receive sufficient information during emergency department orientation about ordering radiological tests out of hours.
Among several recommendations, the analysis said the emergency department should review medical staff orientation to include key work processes such as how to request urgent diagnostic tests out of hours.
