Peta Hickey, a 43-year-old mother of two from Melbourne, died from multiple organ failure in May 2019 as a result of an anaphylactic reaction to contrast dye she was administered for a CT scan. The scan was given as part of a voluntary health check sponsored by her employer despite the woman having no complaints.
Coroner Simon McGregor today announced the findings from an inquest in Ms Hickey’s death. He found that inadequate checks by the health service providers, inadequate anaphylaxis training for the radiologists, and a well-meaning but short-sighted workplace health program all contributed to her death.
Ms Hickey’s was working for Programmed — an employment service — in 2018 when her employer suggested she undergo a voluntary heart screening sponsored by the company after a colleague suffered a non-fatal cardiac arrest. Ms Hickey, who had no history of heart issues, folowed the advice and signed up for the screening.
Despite never having been seen by a doctor, Ms Hickey was referred for a CT scan by Priority Care Health Solutions, a corporate booking service used by the screening service. The company was using the electronic signature of its occupational health consultant, Dr Doumit Saad, on referral forms despite him never meeting the patients.
The coroner found Priority’s practice of inserting Dr Saad’s signature on forms deceived the radiology clinics receiving the referrals.
MRI Now, a medical booking service, set up an appointment for Ms Hickey for a CT scan with Future Medical Imaging Group in Moonee Ponds.
The inquest heard testimony that radiologist Dr Gavin Tseng had only received general anaphylaxis training and was unaware of resuscitation instructions posted at the imaging clinic.
The coroner said it appeared Dr Tseng was not adequately trained or prepared for Ms Hickey’s severe reaction.
Said Coroner McGregor:
The conduct of doctors Saad and Tseng departed from normal professional practices.
It may be somewhat of an oversimplification, but the snapshot provided by this inquest has revealed an industry putting profits over patients.
The coroner found that the introduction of the voluntary health check by Ms Hickey’s employer was well intentioned but did not take into account the risks of prescribing CT scans to asymptomatic patients.
He found the actions of the employer, Priority Care Health Solutions, MRI Now, Dr Saad and Dr Tseng all contributed Ms Hickey’s death.
McGregor issued a number of directives and recommendations:
- He directed the Australian Health Practitioner Regulation Agency be notified that Dr Saad’s actions were unethical and unsafe, and Dr Tseng failed to recognize Ms Hickey’s allergic reaction and administer epinephrine;
- He recommended an Australia-wide mandate that all radiologists working with contrast dye be trained to recognize and respond to severe allergic reactions every three years, and be taught CPR.
- He recommended an official review of appropriate screening for CT angiograms and other invasive cardiac tests in Australia;
- He recommended the Commonwealth health minister produce standard referral forms for diagnostic imaging practices.
The employer issued the following statement at the conclusion of the inquest:
We were deeply saddened by Peta’s tragic death in 2019. Peta was a valued, respected, and well-liked member of our team and she is sorely missed.
As a company, we have welcomed the coroner’s recommendations, which include improving patient communication and pre-emptive medical consultation in programs of this nature.
While we have discontinued the Cardiac Health Assessment Program, and our relationship with Priority Care, our focus has always been, and continues to be, to help members of our team proactively look after their health.
Once again, we would like to express our sincere condolences to Peta Hickey’s family.
We are deeply sorry that a program implemented with the intention of helping and protecting our staff led to the tragic passing of a valued member of our team.
Ms Hickey’s family has vowed to continue pursuing justice following her death. They plan to initiate civil action in their Supreme Court to demand industry changes and compensation.
Our deepest sympathies go out to the family of Ms Hickey and we wish them solace and some measure of closure now that the inquest has been completed. We also wish them much success in their continued quest for justice.
As we do with reports of this kind, we look to ways of preventing similar such tragedies from befalling others in the future.
Invasive procedures — including diagnostic tests involving contrast dyes — should be avoided unless prescribed by a medical practitioner who has examined you first-hand. You should be given a full explanation describing why the procedure is medically necessary, what the procedure is meant to accomplish, and the potential risks involved.
All medical practitioners involved in your care should be advised of known sensitivities or allergies to dyes, anesthesia, and medications. Prior to any invasive procedure, check with the medical professionals involved to confirm they have been apprised of your allergies and have a plan in place to accomodate them. Have them inform you of the actions they will take should you suffer a reaction, and how they determine when to administer epinephrine.
Never assume your specific medical issues (including your allergies and sensitivities) have been adequately transmitted between medical practitioners. To be safe, assume a new practitioner knows nothing of your allergies and be sure to go over your list of concerns with them.