Coroner's Court of Western Australia

Inquest into the Death of Ashleigh Rebecca HUNTER

Inquest into the Death of Ashleigh Rebecca HUNTER

Delivered on : 13 December 2023

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations : Yes

Recommendation No. 1

That the Department of Health consult with Health Service Providers with regard to implementing a single electronic medical record.

Recommendation No. 2

That the Department of Health on behalf of Health Service Providers consult with St John Ambulance to consider pathways allowing real time access to relevant portions of the St John Ambulance electronic medical records system, including sharing of Corpuls Monitor data.

Recommendation No. 3

That the Department of Health on behalf of Health Service Providers consult with St John Ambulance to consider the development of a shared, consistent documentation process to record the deceased’s observations taken by St John Ambulance within the medical records of Health Service Providers.

Recommendation No. 4

That EMHS consider the development of a clear and consistent documentation process to record decisions made by the Emergency Physician in Charge (EPIC) in the event that the EPIC declines to escalate patient care after a request is made, or a concern is raised, by a clinician.

Recommendation No. 5

That the Department of Health consult with relevant stakeholders to develop a body of work to establish a working definition of an “emergency,” for the purposes of:

  1. Developing strategies to reduce Emergency Department overcrowding;


  1. Educating the community and building awareness about “responsible use” of an Emergency Department, including the use of examples of specific situations in which Emergency Department services could appropriately be used, or not used.

 Recommendation No. 6

That EMHS consider additional education and audits on the use of the “Adult Sepsis Pathway,” with additional educational focus on encouraging a high index of clinical suspicion for sepsis by clinicians,

including nurses who undertake triage assessments, who may ultimately treat a patient with an unusual sepsis presentation.

Recommendation No. 7

That clear guidelines between the Department of Health, hospitals (including East Metropolitan Health Service), and St John Ambulance be established regarding the duties and responsibilities of St John Ambulance Paramedics or Ambulance Officers to escalate patients, in circumstances where there is ambulance ramping, or any other delay in assessment of a St John Ambulance patient by a Triage Nurse.

 Recommendation No. 8

That the Department of Health consider funding an established nongovernment organisation to develop and implement a Public Awareness Campaign regarding the availability of the Meningococcal ACWY vaccine, and the Meningococcal B vaccine, to advise those who want to

protect themselves against meningococcal disease that they can speak to their vaccination provider about getting vaccinated, particularly the cohort that would not have been vaccinated within the free National Immunisation Program.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Ms Ashleigh Hunter (Ashleigh) died at Royal Perth Hospital on the afternoon of 27 December 2019 from a meningococcal infection after being taken there by ambulance at approximately 1.16 pm and then waiting outside the ED, first on the Ramp and then in the ABay, for approximately one hour.  The ED was overcrowded that day, and the hospital had implemented the ED Capacity Procedure. 

The Triage Nurse who triaged Ashleigh between 1.29 pm and 1.32 pm allocated her a Triage Code of 3, which meant she should ordinarily have been assessed and treated by a doctor within 30 minutes. A Triage Code of 3 also meant that Ashleigh was eligible to be placed on the “Ramp” location outside the ED, and this is what occurred.  On the Ramp, Ashleigh remained under the care of the St John Ambulance officers, who monitored her observations. 

However, a Triage Code of 2 would have seen Ashleigh taken off the Ramp and into the ED, to be assessed and treated by a doctor within 10 minutes. 

The inquest explored the appropriateness of Ashleigh’s triage to Code 3, and whether it should more appropriately have been a Code 2 (denoting a greater clinical urgency).  While the State Coroner was satisfied that within the limits of the systems and procedures available, there was no criticism of Ashleigh’s triage, the State Coroner expressed her concern about the Triage Nurse being placed in a position of having to make such an impactful and finely balanced decision against the background of being informed that the ED Capacity Procedure had been implemented and there were not enough ED cubicles.

After spending between 24 and 29 minutes on the Ramp, Ashleigh was placed in the ABay under the care of the ABay Nurse, between 1.40 pm and 1.45 pm.  The ABay Nurse, concerned about Ashleigh’s condition, took her into the ED at approximately 2.16 pm, where she was seen by a doctor.  Shortly afterwards, at 2.28 pm Ashleigh went into cardiac arrest and despite all efforts at resuscitation tragically she was unable to be revived.

The State Coroner found that as a consequence of the systems and procedures of East Metropolitan Health Service and Royal Perth Hospital, there were missed opportunities to identify the seriousness of Ashleigh’s condition earlier, and that the quality of care and treatment afforded to Ashleigh was below the standard that ought to be expected of a public hospital in Western Australia.

The State Coroner heard from a number of highly qualified experts on the question of whether Ashleigh may have survived if she had received prompt medical treatment following her arrival at Royal Perth Hospital.  On the question of survivability, and whether Ashleigh’s death was preventable, the State Coroner was satisfied that while Ashleigh had a rapidly progressing disease, her prospects of survival, with prompt medical treatment, while very slim, were not wholly absent.

The State Coroner was also satisfied that while it could not be established that the delay in Ashleigh’s treatment contributed to her death, it most likely affected the time of her death by bringing it forward.  The State Coroner explored a number of areas concerning Ashleigh’s care and treatment including the question of whether there was a focus on her consumption illicit drugs (causing symptoms to be prematurely and erroneously attributed to drug use), the lack of pain relief, ED overcrowding, and the fragmentation of care as Ashleigh passed through the Ramp and ABay areas.

The State Coroner made a number of recommendations directed towards avoiding future deaths in similar circumstances.

Catch Words :  Royal Perth Hospital; meningococcal infection; sepsis; Adult Sepsis Pathway; ED overcrowding; delay; triage; ambulance ramping; patient ramping; ABay; pain management; definition of “emergency”.

Last updated: 10-Jun-2024

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