SA coronial finding exposes dangerous patient safety gap

10 October 2018
Lawyers and the family of a man who died from administered opioid medication at the Flinders Medical Centre have called for an urgent improvement to patient safety after the South Australian Deputy State Coroner Bashir found his death was preventable.

53 year old Stephen Robert Atkins attended the Flinders Medical Centre emergency department in 2015 complaining of neck and arm pain as well as an eye problem.

While in hospital, Mr Atkins was administered Fentanyl and Oxycodone to manage his pain and today the Deputy State Coroner has found the toxicity of this combination caused his death three days later.

Maurice Blackburn lawyer, Emma Thornton said the series of failures and omissions which lead to Mr Atkins’ untimely death at the hospital were enormously disappointing.

“Mr Atkins was admitted to hospital suffering pain, not a life-threatening condition. Yet tragically, he never came home to his family,” Ms Thornton said.

“Tellingly, the Coroner points out that if the hospital had simply followed its own protocols, then Mr Atkins should still be with us today.

“This finding demonstrates there is an urgent need for better medical staff training around the protocols that already exist and if there are any gaps in those protocols, they must be addressed immediately to ensure every patient’s safety.”

Ms Thornton said the death of Mr Atkins has also shown there must be greater education and awareness among medical staff about the potential effects of opiate medication and recognising its impact on a patient.

“Hospital staff need to be better equipped in the treatment of patients with acute pain, the effects of particular medication, and the need for close and frequent monitoring,” Ms Thornton said.

Mr Atkins’ widow, Lee-Anne Atkins has thanked the Deputy Coroner for the thorough investigation into the cause of her husband’s death.

“It has been a long and arduous time us all and we as a family have struggled to come to terms with his death as it entirely preventable and should never have been allowed to occur.

“On numerous occasions we raised our concerns with medical staff, but sadly this wasn’t enough.

“Our lives have changed forever, but we do hope that the Coroner’s recommendations are adhered to so these mistakes are not repeated and nobody else has to experience this nightmare,” Mrs Atkins said.

Practice Areas: