SA coroner blasts stroke death reports

Authorities might not be able to investigate two stroke deaths at Royal Adelaide Hospital in April because they weren’t properly reported.


State Coroner Mark Johns says SA Health’s tardiness in providing him with necessary details about the deaths means it’s likely too late to order autopsies, making it impossible for him to piece together what happened.

Mr Johns says only one of the deaths was the subject of a timely report but it failed to mention that a neuro-interventionist had been unavailable at the time, which might have contributed to the death.

“Had the coroner been aware of that information when the death was reported, it is likely he would have directed an autopsy. It is now too late for that,” he said in a statement on Tuesday.

Mr Johns said he was forced to seek information from SA Health about the second death after learning about it in the media and is waiting to receive case notes.

He said he believed the situation was another example of junior medical officers with little connection to a patient preparing medical reports of death.

“That practice results in a lack of transparency,” he said.

Mr Johns also chided SA Health for making “misleading” statements about how it reported the deaths.

“It is misleading to allow the public to think it was reported in a manner that would enable the coroner to investigate effectively the issues that are now emerging,” he said.

SA Health said under law, medical practitioners reporting a death to the coroner are obliged to provide their own opinion of the cause of death and it is not the department’s place to interfere with it.

“It is not for SA Health to intervene in their clinical opinion,” the department said in a statement on Tuesday.

“We’ll continue to work with the coroner’s office about the information they require in cases such as these going forward.”