On the Facebook version of this page I posted links to news stories relating to the death of Stacy Yean.
- Guy Stayner, ‘Ballarat woman died after being told she was not sick enough for hospital, inquest told’ ABC News (Online) (1 Mar 2017); and
- Emma Younger ‘Stacey Yean’s death not fault of paramedics who advised her not to go to hospital, coroner finds’ ABC News (Online) (23 Mar 2017).
For this blog I have gone to the findings of the Coroner, Philip Byrne.
Ms Yean was 23 years old. She became very ill on 5 January 2016. After 2 hours, the family called the local hospital for advice and was told to contact her doctor. A call was made to the doctor but the doctor was unavailable and the locum service did not provide house calls in that area.
At 3.15pm a call was made to triple zero. The initial call taker triaged the call as non-life threatening and it was transferred to Ambulance Victoria’s referral service. A paramedic took the call and determined that an ambulance was not required but the family were invited to call triple zero again should circumstances change.
At 4.30pm another triple zero call was made and an ambulance was dispatched. The ambulance was staffed by an experienced paramedic educator and a graduate paramedic who had been ‘on the road’ for only 2 weeks. The paramedics took two sets of observations, 10 minutes apart, and concluded that Ms Yean ‘may have a “gastric bug” and [her] presentation did not mandate transport to hospital’. They offered to take her to hospital but did advise that the hospital was busy and she was likely to face a long delay in being seen. In light of the advice, Ms Yean declined the offer of transport to hospital.
Ms Yean came out of her bedroom at 11pm and spent some time with her father before returning to bed. She appeared to be asleep at 1am. At 11am she was found deceased in her bed. An autopsy, including toxicology, biochemical and microbiological analysis, failed to identify the cause of death.
In the circumstances the Coroner held a full inquest with oral evidence from those involved.
Matters in contention
One can only imagine the heartbreak that Ms Yean’s family must have felt. They called triple zero, their daughter was not taken to hospital, and she died.
In a poignant statement, Mr James Yean said:
“I am sure that if she was taken to hospital on the 5th of January 2016, my daughter Stacey would still be alive”.
In a letter to the Court dated 11 May 2016 Mrs Adrienne Yean wrote:
“If the right call had been made Stacey would still be with us today or at the very least she would have passed in a hospital setting with people who could have tried to save her life, not alone in her room.”
The fundamental thrust of the family’s position is that claimed deficiencies in the management of Ms Yean on the afternoon of 5 January 2016 were causal factors in her death.
In light of the family’s concerns the coroner undertook a detailed investigation into the response by Ambulance Victoria.
The 3.15pm triple zero call
This call was referred to the referral service and no ambulance was sent. In a review of the call, Ambulance Victoria identified that various questions, required by the triage procedures, were not asked. The coroner considered the impact of that failure but concluded that, even if those questions had been asked, the outcome would have been the same. The failure to send an ambulance at 3.15pm did not contribute to Ms Yean’s death because her ‘condition did not deteriorate or alter significantly’ between that time and 4.30pm when the second triple zero call was made and an ambulance was despatched.
The assessment by paramedics at 4.30pm
There was an issue as to whether or not the paramedics refused to transport Ms Yean to hospital. After some evidence it was conceded that they paramedics had offered to transport her but had warned Ms Yean that there was likely to be a significant delay. According to the family, it was said ‘that she might have to wait in the Emergency Department for 5-6 hours with a bucket between her legs.’ The paramedics confirmed that they did advise there would be a wait, but denied that they specified a particular time.
Ms Yean’s father said that he offered to drive his daughter to hospital but she declined because of the advice received from the paramedics, that there would be a long delay. Counsel for the family asked the coroner to find that the advice, and consequent decision not to go to hospital, contributed to Ms Yean’s death. The coroner did not make that finding. He said:
While the prospect of a significant wait in the Emergency Department was no doubt one of the factors, perhaps even the main reason Ms Yean declined the offer of transportation, that cannot reasonably be seen as causal or contributing factors in her subsequent death; it was merely stating a likely fact.
He went on (emphasis in original):
I find the interpretation put on the issue of transportation by both parties, AV and the family interesting. Ms Handley [one of the paramedics] states Ms Yean “refused” the offer of transportation. I would have thought a more appropriate interpretation would be “declined” rather than “refused”. The family maintain Ms Yean was “talked out” of going to hospital; both interpretations are, in my view, strained.
I do not consider it unreasonable for a paramedic to advise a patient there may well be a significant delay in being seen at an Emergency Department, particularly if that paramedic has observed ambulances “ramped” earlier in the day. The decision taken, while no doubt influenced by the prospect of a significant delay, ultimately was taken by Ms Yean, I do not accept she was refused transport to hospital.
The bottom line is, the offer of transportation was made, but declined. Of course no one could have predicted the tragic event which unfolded sometime overnight, at a time I am unable to determine.
Professor Stephen Bernard, Senior Medical Advisor to Ambulance Victoria gave evidence. He confirmed that the actions by the paramedics were in accord with then clinical practice guidelines. The coroner said (emphasis in original):
Bearing in mind that the paramedics are the professionals, I suggest that in the final analysis their assessment of the patient, following clinical guidelines, is the appropriate basis upon which a decision is taken to transport, or not.
Having carefully reviewed the evidence … I have concluded that [the paramedics’] … assessment of Ms Yean’s condition was in accordance with AV’s clinical practice guidelines, their performance did not depart from a norm or standard, nor did it fall short of a recognised duty. Consequently, in my considered view, I conclude the weight of the evidence does not warrant the making of an adverse finding, or indeed comment, against the paramedics or AV.
Finally the family claimed that during an Open Disclosure process, designed to work with the family to explain and explore what had happened, a representative of Ambulance Victoria conceded that Ambulance Victoria had been at fault in the way Ms Yean was treated. The Coroner observed (emphasis in original) that:
Over the years I have quite often observed a mere apology or expression of sympathy construed as an acknowledgement of fault/culpability when clearly it is not.
I do not accept the contention that … on behalf of AV, admitted a deficiency in performance by AV staff. I believe any belief to the contrary is likely founded upon a misunderstanding, miscommunication, misinterpretation or a combination of all three, of what Mr … sought to convey.
Let me first acknowledge the terrible tragedy in this case. The family of Ms Yean did all that they could do, they sought medical advice and acted on it. As a parent one hopes that this will lead to the best outcome but in this case the outcome was as bad as it could be. One can understand their grief, frustration and loss and belief that someone, Ambulance Victoria paramedics, let them down.
For the paramedics this too must be a tragic case. They gave their honest advice and opinion and their patient died and they had to spend a year reliving the matter for the coroner. For one of the paramedics, with only 2 weeks on road experience, this will no doubt be a formative experience in their career. We can only feel sympathy for them, too.
Elsewhere I have argued that paramedics should not be required to transport everyone – see:
- Transport everyone or act as a professional? A question for paramedics (May 6, 2013); and
- Do paramedics have to transport everyone? (February 3, 2014).
This case highlights the risk of not transporting everyone, but as the Coroner noted:
It is possible perhaps even probable, that Ms Yean, even if transported to hospital, would have been discharged home, probably after the provision of an anti-emetic medication, rather than be admitted.
The coroner was not critical of the decision to advise Ms Yean of the likely delay nor of the decision of Ms Yean to choose not to go to hospital. Paramedics are professionals and are there to exercise their professional judgment. They could not have foreseen the consequence in this case.
The tragedy here is that there is no doubt that everyone was trying to do the best that they could for Ms Yean. The family sought medical advice; the advisors gave their honest opinion that her condition did not warrant hospital treatment and that if taken to hospital there would have been significant delays. Given that, even now it is not known what caused Ms Yean’s death, it can’t be said that any decision was wrong or that transporting her to hospital would have made a difference.
The sooner all Australian Ambulance Officers are ‘Registered’ by AHPRA, the better …
I wouldn’t be as sympathetic to the Ambos as some may be …
Firstly, what meant by “very ill” ? What did the family tell the ambos ?
I hate hearing about “obervations” ( vital signs ) as being the determinant of clinical risk.
Having a BP of xyz does NOT mean ‘this or that’. However, there is no ‘supportive’ statement from either party, to link the ‘observations’ with the description of “very ill”. Did “very ill” mean vomiting ? Did it mean diarrhoea ? Did it mean difficulty in breathing ? A moderate to high temperature ( greater than 37.6 ) ‘should’ be more clinically relevant than a BP. These type of ‘observations’ are more important that a BP or heart rate – though in combination, they do mean something. Problem with this case, is there is nothing in the story to give a more ‘global assessment’ …
I thought ambos were supposed to work by ‘protocols’ ? What gave them the right to diagnose “gastro bug” ??
This term “gastro bug” has been associated with multiple sudden deaths for both for inpatients and those in the pre-hospital environment. Ambos should not be making such assertions with limited ‘observations’, to include the oral history from ‘the family’.
To keep them clear of allegations, they should have recommended transport, and pass the responsibility over to a doctor in the ED.
I don’t know what the Victorians do, but in NSW, you are unlikely to be ‘sitting around’ for several hours, waiting to be seen … if you arrive in an Ambulance. No Ambulance presentation will be Triaged at a grade less than three ( 3 ). That means, you must be ‘seen’ within 30 mins. ( under ordinary operating environment ).
In summary, I would be ‘jumping up & down’ if I was a relative of the deceased patient. However, if I was there …. I would have DEMANDED transport ….
Gordon, I can’t agree with all your comments. If paramedics don’t have the opportunity to exercise professional skill and judgment, and give advice then there is no need for them to be registered. If their actions are limited by prescribed protocols and they have to transport everyone they are returned simply to the role of ‘ambulance driver’.
As for what did the family tell the ambo’s and what were the observations, the coroner discussed that in some detail. There were issues about what was said to the paramedics and how Ms Yean presented to them. In examination of Professor Bernard, counsel for the Ambulance Service invited him to accept ‘that the family’s claims as to Ms Yean’s presentation to the paramedics, sweating profusely, wet hair, the prospect of a level of dehydration were true’ and to then consider that those symptoms required transport to hospital. Professor Bernard said that even with those symptoms, under clinical practice guidelines that were in place at the time of Ms Yean’s death and those that were introduced after 5 December 2016, Ambulance Victoria ‘would not consider her to be at risk’.
With respect to the history given by the family the Coroner said (at -):
As for the claim that the ‘Problem with this case, is there is nothing in the story to give a more ‘global assessment’ …’ remember that the Coroner is not reproducing all the details and case sheets in order for others to form their own view. He is reporting on his view having considered those documents and the evidence of those called. He’s identifying what he sees as important. Remember that his job was to determine if the actions of the paramedics contributed to Ms Yean’s death. As he says (at , emphasis in original):
We all know that Ms Yean died, but the paramedics didn’t know that at the time. There is a risk that any patient not transported will die, but common sense and experience says that not everyone who calls an ambulance needs transport.
Today paramedics work to clinical practice guidelines, giving more room for judgment, rather highly prescriptive protocols. As for what ‘gave them the right’ they were called and asked for their opinion. No-one knows whether their diagnosis was correct or not. As noted above, the paramedics did take into account the history given as well as the patient’s observations and the evidence is that the conclusions reached, and the advice given, were reasonable in the circumstances.
As for “To keep them clear of allegations, they should have recommended transport, and pass the responsibility over to a doctor in the ED” that again denies professional responsibility. If you’re only thought is ‘how do I cover my arse’ you’re not acting as a professional or in the patient’s best interests. They were not, nor should they, focus on ‘keeping clear of allegations’ but on the patient’s needs, which is what they did. Transporting someone to hospital to sit in casualty for hours only to be discharged home – the reasonable expectation in this case – may not be in the patient’s best interests.
As for the claim that “No Ambulance presentation will be Triaged at a grade less than three (3). That means, you must be ‘seen’ within 30 mins”. Do you have any evidence for that as it is contrary to the advice given by NSW Ambulance (see http://www.ambulance.nsw.gov.au/Media/docs/FAQ-dac56c45-b444-429f-a1f5-33cda35f907b-0.pdf) –
The relatives of Ms Yean are and have pushed for answers and that is why there was a full autopsy and coronial inquiry but remember the advice of the coroner, the actions of the paramedics have to be judged without the benefit of hindsight – the did not know and could not know that Ms Yean was going to die.
As for demanding transport, if that had happened she would have been transported, but remember people can’t demand treatment that’s not warranted and, further, the decision to accept transport (or not) lies with the patient not a family member.
I’ve never seen a NSW Ambulance bring in a patient for them to be redirected to the ‘waiting room’. I think that ‘fact sheet’ was created in an attempt to limit the ‘less than urgent’ cases presenting to ED.
When Ambulance officers do become Registered by AHPRA, they will be subject to the strict discipline that Nurses (and all other Registered Health Professionals ) have to endure, to include complaints being referred to the HCCC – which any member of the public can initiate ( eg. family of patient ).
In cases like this one, where the person was not transported and later died, the level of inquiry will become far more intense.
How many people have to die, before a health-related policy or procedure is changed ?
( I’m sure NSW Health actually have a numerical trigger ! )
The problem is that to everyone, Ms Yean’s case appeared to be a ‘less than urgent’ case. I can’t see that an investigation by the Paramedicine Board would be far more intense than a coroner’s inquest. The coroner has more extensive powers of compulsion and can order an autopsy which happened here. I doubt an allegation of unsatisfactory professional conduct would go anywhere here. The question has to be asked ‘what else were they meant to do?’ and if you say ‘transport’ then it follows they have to transport everyone regardless of the nature of their illness or injury or presenting symptoms, but is that really what we want? And I very much doubt NSW Health have a numerical trigger to change policies, we’re all going to die and policy choices do limit the capacity to save all lives. I’m sure, like in this case, they do a review and ask ‘was there anything else we could or should have done’. The Coroner could have recommended changes if he thought they were necessary, but he did not.
A review of the AV CPGs places ‘Acute or undiagnosed abdominal pain’ as a RED FLAG and is clear not to use the Vital Signs alone to make a diagnosis. Transporting is considered in general the most ‘appropriate treatment’ of such a patient.
However not being privy to the full details, can’t comment on this particular case, other than to say comments in this article about ‘Acute or undiagnosed abdominal pain’ being reasonable to leave at home is not the standard of care that has been taught and is not supported in the AV CPGs despite what was stated. It would be very sad if this situation has changed.
Many older Paramedics raised concerns of the recent changes to the AV Dispatch Grid aimed at reducing the number of responses to free up Ambulances aimed at reducing response times, rather than adding ambulance resources, believing it would result in deaths. I guess those fears were realised here.
Hi Gordon, I’ve never worked in a NSW emergency department but am a Registered Nurse (ED/ICU) as well as a Paramedic. The arrival mechanism (eg ambulance, helicopter, walk in) has no bearing whatsoever on the Australasian Triage (ATS) Scale allocated to the patient. An Ambulance can, will and should be allocated anything from a Category 1 to a Category 5.
I have allocated and been on the other end of these allocations in three Australian jurisdictions. NSW may have some interesting local arrangements but if they did it they would go against the principle of triage which is to determine and assign urgency. Ambulance patients can and should wait longer than a more urgent “walk in”. It would also go against the principles of the College of Emergency Medicine and the College of Emergency Nursing Australia who have a collective goal of consistent application of the ATS.
Unfortunate outcome to what would have likely been a routine job. Especially given a Paramedic Educator was onboard. We can’t save them all.
Thanks for the analysis.
@Gordon – Just to clarify; I would have thought that NSW Ambulance Paramedics are already under the remit of the NSW HCC (which after reading their website also manage complaints made against AHPRA professionals too) – why do you think paramedics being registered alter the type of investigation – especially if themed to the case being discussed here..??
Being an SA based healthcare provider, I’m intrigued by the NSW HCC model / process and wonder how many of the complaints it receives, would be automatically referred to AHPRA or the associated professional body (I do note that NSW has another body called the Health Professionals Council Authority – not sure how they fit in to the process).
Within SA, we have the Health and Community Services Complaints Commissioner (http://www.hcscc.sa.gov.au/frequently-asked-questions/) who oversees the Code of Conduct for Unregistered Health Practitioners, which includes ‘ambulance services’.
SA Health have a state policy that talks about Consumer Feedback Management – http://www.sahealth.sa.gov.au/wps/wcm/connect/487052804cc87304b615b6a496684d9f/Directive_Consumer+Feedback+Management_v3.5_21032017.pdf?MOD=AJPERES&CACHEID=487052804cc87304b615b6a496684d9f
@ Michael – maybe a topic for another time, but will registration of Paramedics see any real change to complaint handling and outcomes, either at a jurisdictional level or peak body/national level..?? (other than the possible removal/restriction of registration practice, which I image can be done somewhat now by an employer internally – ie restrict practice/impose conditions following the outcomes of a complaint and subsequent investigation.
AHPRA doesn’t investigate NSW based health professionals – they get referred to NSW HCCC, who are the ‘Spanish Inquisition’ …… much tougher to deal with ( no personal experience, touch wood !! )
Employers can internally restrict a paramedic’s practice but that doesn’t stop them getting a job elsewhere. And employers can fire staff but with national registration that will be harder if the tribunal thinks there conduct was ok. It will also mean that aggrieved people don’t have to complain to the employer that has an interest in protecting its own reputation. In either case so it will allow paramedics to judge there colleagues rather than the employer and that will be a pretty significant change.
I note the coroners remarks that they did not consider it unreasonable for a paramedic to advise a patient there may be significant delay. I’ve always thought hospital wait time is a reasonable piece of information to discuss with a patient when determining transport or non transport in a case without life threatening or medically urgent symptoms.
I guess what I’m interested in does the coroners statement form any sort of precedent that may be applied in future cases and would offer some sort of reassurance to Paramedics that may advise patients of possible hospital wait times. If there is any sort of precedent or reassurance from this statement would it apply in another jurisdiction.
Or am I looking at this from the wrong angle? Is this just a mere statement by the coroner and not a legal precedent? Does the Coroners court “create” legal precedents?
A coroner’s findings is some form of ‘precedent’. The online Oxford English Dictionary defines precedent (https://en.oxforddictionaries.com/definition/precedent) as:
A coroner’s findings are a precedent as defined in (1), above, that is they are an earlier case that might be considered as an example or guide, but they are not binding, that is they are not a precedent as defined in (1.1).
The hierarchy of courts and the doctrine of precedent is described in an earlier post – Accessing a judge or magistrate’s reasons for decision (November 18, 2016). Coroner’s courts don’t appear in the diagram on that post as coroner’s courts are not courts of law. A coroner holds an inquest (into a death) or an inquiry (into a fire). A coroner is not bound by the rules of evidence and a coroner does not determine, or adjust, legal rights. A coroner can’t find anyone guilty of an offence, a coroner can’t determine that a person was, or was not negligent, a coroner can’t send anyone to gaol, impose a fine or award damages. A coroner makes inquiries into the circumstances surrounding a death or fire to make sure ‘foul play’ isn’t overlooked and to make recommendations, where relevant, to try to avoid a repeat of the circumstances that lead to this death or fire.
A coroner’s recommendations are just that, they are recommendations. No-one is obliged to implement a coroner’s recommendations. The agency to which they are directed may be required to consider them, but they are not required to implement them. For further details see:
* The role of the coroner (May 22, 2013); and
* What is the difference between an inquiry and a court? (June 24, 2015)).
A coroner’s findings are therefore an earlier event that may guide subsequent events. At the next death or fire where it’s found that an earlier recommendation wasn’t adopted questions will be asked; and equally if it is found that an earlier recommendation was adopted those involved will no doubt point to that as showing they did all that they reasonably could. But it is not a legally binding precedent.
Because a coroner is conducting an inquiry into a particular death or fire he or she will make findings about that event, the next event will be different. The finding in the inquest into the death of Ms Yean that the conduct of the paramedics was reasonable does not mean that similar conduct must be held to be reasonable in the future, as the circumstances will be different.
Is there reassurance to be found from this sort of statement? I would think there is. First it shows (despite constant questions to this blog) that coroner’s are not out to get the emergency services nor if someone dies a coroner is going to blame the paramedics or firefighters. The reassurance is that the coroner listened to the evidence and gave a practical review of the event to ask ‘could or should something different have happened?’ The paramedics involved had tough questions to answer, but just because you’re asked a tough question does not mean you don’t have an answer.
Second although it’s not a binding precedent, in similar circumstances lawyers would no doubt draw the next coroner’s attention to the findings to say that ‘this coroner thought this conduct was reasonable, you should do the same…’ The second coroner isn’t bound to do that (it’s not a legal precedent) but would no doubt be interested in considering the similarities and differences with any case before his or her court.
The short answer is that a coroner’s inquiry/inquest does not create a legally binding precedent; but it can and should inform the culture of agencies and where a coroner, as in this case says:
Then Ambulance Victoria and other ambulance services can look to that and conclude that there has been a review of their practices and that independent review did not find them wanting, and that can be used to reassure them and the paramedics that their conduct is appropriate even when there are tragic outcomes.