In Inquest into the death of Peta Hickey the Victorian Coroner comments that the patient -
died as a result of substandard clinical judgement from doctors at the beginning and end of this programme, combined with a misalignment of incentives amongst the various business entities that facilitated the process. It may be somewhat of an oversimplification, but the snapshot provided by this Inquest has revealed an industry putting profits over patients.
That comment is reflected in a recommendation regarding exploration by The Australian Competition & Consumer Commission.
The Coroner states
The Cardiac Health Assessment Programme (CHAP) was a snapshot test of Australia’s system of private diagnostic imaging practices, sending scanning referrals, insufficient in both clinical details and follow up contact information, to an almost random selection of practices throughout Australia. Despite these deficiencies, every scan was performed and the checks and balances the industry believed were present failed.
Ms Peta Hickey, wife, mother of two young children and successful business executive, found herself amongst this unfortunate cohort, even though she had no history of heart problems.
In early June 2018, a labour hire firm called Programmed sought a provider to deliver a ‘medical assessment program for heart health’ for its executives, via a ‘corporate deal’. Programmed contacted a corporate booking service, operating in the health area, Priority Care Health Solutions (Priority), to facilitate and co-ordinate the programme.
In early June and July of 2018, Programmed was told by a doctor of a potential medical assessment programme for heart health that could be offered to their executives, being a combination of heart check tests – a “Coronary artery CT calcium scores with angiogram”.
Ultimately, Programmed was advised these tests were the CT coronary angiogram (CTCA) and a Coronary Artery Calcium score (CAC). Both tests were to be performed more or less simultaneously, in the one sitting. ...
On 26 October 2018, Programmed formally engaged Priority to co-ordinate the CHAP for the first cohort of Programmed participants, which included the CT scan.
At some time in late 2018, Priority engaged Jobfit, a company which provides corporate or ‘bulk medical assessments’ involving occupational health medical services (including pre-employment fitness assessments), throughout Australia and New Zealand. Jobfit was engaged to review the CT scan test results of Programmed executives and to allocate executives to their doctors for this purpose.
A doctor employed by Jobfit, Dr Doumit Saad, performed CT scan test result reviews for the first and then a second cohort of Programmed participants.
In March 2019, Programmed invited Peta, by email, to undergo the CHAP. A Priority email to Peta set out the steps of the CHAP and stated that a company named MRI Now will arrange the “diagnostic imaging referral”.
MRI Now is a Medical Image booking concierge service that also provides independent radiological opinions via their network of radiologists (MRI Now). MRI Now does not provide medical assessments, so in the case of the CHAP, it assisted patients to find options to attend an Imaging Centre for their CT scan.
So, Priority referred CT scan bookings to MRI Now. MRI Now then engaged various imaging providers to facilitate the scans, including the Future Medical Imaging Group, a private radiology practice with six locations in Victoria. So it was ultimately MRI Now who assisted Peta to find an imaging centre to attend, being the Future Medical Imaging Group clinic located in Moonee Ponds (FMIG).
The form used to book Peta into FMIG for the CT scan procedure was headed “MRI Now – Booking Confirmation” dated 12 March 2019 (the booking form).
The booking form appears to include an MRI Now ‘referral form’ (the referral), received by MRI Now from Priority, bearing Saad’s name as the referring doctor and Saad’s electronic signature. The referral did not include any clinical notes.
Dr Saad had not had any involvement in Peta’s care prior to the CT scan.
Peta had no medical history of cardiac problems but agreed to undergo the CT scan.
On 1 May 2019, Peta attended FMIG for the CT scan. ...
Following the administration of the IV contrast dye for the CTCA, Peta suffered an allergic reaction to the contrast dye.
A call to emergency ‘000’ call was placed by FMIG office manager, Liezl Samakovski, to the Emergency Services Telecommunications Authority (ESTA), seeking the assistance of Ambulance Victoria. ...
Peta did not regain consciousness and died on 9 May 2019. ...
Peta died as a result of substandard clinical judgement from doctors at the beginning and end of this programme, combined with a misalignment of incentives amongst the various business entities that facilitated the process. It may be somewhat of an oversimplification, but the snapshot provided by this Inquest has revealed an industry putting profits over patients.
Two main issues arise from the circumstances surrounding Peta’s death: whether she should have undergone the CTCA scan at all and whether FMIG staff should have been able to better manage her anaphylactic reaction to prevent her death.
The Coroner's recommendations are
radiologists
1. That the Royal Australian and New Zealand College of Radiologists (RANZCR) implement a mandatory requirement that radiologists working in settings where contrast is administered without other expert medical support undertake specific training in the recognition and management of severe contrast reactions and anaphylaxis every 3 years.
2. That RANZCR, the Australasian Society of Clinical Immunology and Allergy (ASCIA) and the Australian Resuscitation Council (ARC) develop and implement a comprehensive training and certification programme for radiologists in the recognition and management of severe contrast reactions and anaphylaxis and the provision of CPR and basic life support including airway management with equipment available in radiology practices.
3. That RANZCR implement a register of severe contrast reactions, their management and outcomes to enable an assessment of the effectiveness of training and compliance with guidelines.
4. That RANZCR amend its contrast reaction management guidelines for display in rooms where contrast is administered to specifically highlight: (a) that adrenaline is potentially life-saving and must be used promptly. Withholding adrenaline due to misplaced concerns of possible adverse effects can result in deterioration and death of the patient. (b) the role of glucagon in reactions in patients undergoing cardiac CT who have received beta-blocking medication.
5. That RANZCR amend their Standard 5.3.2 with regard to requests for non- emergency and invasive investigations or procedures, or procedures including administration of contrast dye, so that referrals containing no or inadequate clinical information regarding the test or procedure are rejected or referred back to the requesting doctor if that doctor cannot be directly contacted to provide their clinical indication for requesting the test or procedure.
6. That RANZCR prepare a joint position statement with the Cardiac Society of Australia and New Zealand regarding when ‘screening’ is an acceptable indicator for a CT angiogram or other invasive cardiac tests.
7. That RANZCR prepare joint position statements with other relevant bodies on when ‘screening’ is an acceptable indicator for other imaging procedures.
8. That, after these statements are prepared, RANZCR update its standards and guidelines regarding both clinical requests and consent procedures to address the increasing prevalence of ‘screening’ requests, and to ensure that imaging procedures are not performed for ‘screening’ when lower-risk alternatives might achieve the same end.
radiographers
9. That the Medical Radiation Practice Board (MRPB) review and update its set of Professional Capabilities for Medical Radiation Practitioners to ensure that emergency response is adequately addressed within them, including both proficiency in recognition of reactions, administration of necessary treatments, and playing an active role in emergency response, including raising issues with more senior staff when required.
10. That the MRPB update their CPD guidelines to require that all radiographers who work with contrast media ensure they are consistently trained in emergency response to severe reactions and anaphylaxis.
11. That RANZCR, ASCIA, Australian Resuscitation Council and the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT) develop and implement a training and certification programme for radiographers in the recognition and management of severe contrast reactions and anaphylaxis, CPR and Basic Life support with a triannual recertification requirement, including: (a) the ability to administer adrenaline via autoinjector when encountering a patient experiencing a severe reaction; and (b) playing an active role in emergency response, including raising issues with more senior staff when required.
12. That the MRPB, RANZCR and ASMIRT consider expanding radiographers’ scope of practice to include training in the preparation and administration of medications appropriate to their practice, including drugs used to treat medical emergencies encountered in radiology, either under the supervision of a medical practitioner or, in emergencies, without the supervision of a medical practitioner.
private diagnostic imaging practices
13. That FMIG stock adrenaline auto-injectors (in addition to vials of adrenaline) as a means to enable the rapid administration of an accurate dose of adrenaline by the correct route.
14. That FMIG revise their consent process to include a consent form for CTCA and other contrast procedures that is clearly identified as a consent form requiring witnessing by an appropriate person (radiographer or radiologist) and which includes specific reference to items in the RANZCR guideline including radiation risk and alternatives appropriate to their individual circumstances.
15. That RANZCR update its standards regarding radiology practices to ensure:
1. (a) That adrenaline auto-injectors (in addition to vials of adrenaline) are accessible in every room where contrast medium is injected as part of a diagnostic imaging procedure.
2. (b) That policies and procedures for responding to inappropriate requests specify that the response must occur promptly after receipt of the request.
3. (c) That the information required to be given to patients during consent procedures include alternatives which may be appropriate to their individual circumstances.
4. (d) That all radiographers are trained in the recognition and management of anaphylaxis and severe contrast reactions.
5. (e) That practice staff, including but not limited to radiographers, are trained and empowered to play an active role in emergency response, including raising issues with more senior staff when required.
6. (f) That practices have onboarding systems for new radiologists which include an orientation with regard to the location of emergency equipment as well as an assurance of the recency of training with respect to recognition and management of severe contrast reactions and anaphylaxis.
7. (g) That all rooms where contrast medium is administered are to have a contrast reaction treatment guideline prominently displayed.
16. That the Diagnostic Imaging Accreditation Scheme (DIAS) Advisory Committee review the current DIAS Practice Accreditation Standards and propose revised standards, or means of applying the current standards, that ensure:
(a) That adrenaline auto-injectors (in addition to vials of adrenaline) are accessible in every room where contrast medium is injected as part of a diagnostic imaging procedure.
(b) That policies and procedures for responding to inappropriate requests, as required in Standard 2.1, specify that the response must occur promptly after receipt of the request.
(c) That the information required to be given to patients under Standard 2.2 include alternatives which may be appropriate to their individual circumstances.
(d) That Standard 2.4 requires that all radiographers are trained in the recognition and management of anaphylaxis and severe contrast reactions.
(e) That Standard 2.4 requires that practice staff, including but not limited to radiographers, are trained and empowered to play an active role in emergency response, including raising issues with more senior staff when required.
(f) That practices have onboarding systems for new radiologists which include an orientation with regard to the location of emergency equipment as well as an assurance of the recency of training with respect to recognition and management of severe contrast reactions and anaphylaxis.
(g) That all rooms where contrast medium is administered are to have a contrast reaction treatment guideline prominently displayed.
17. That RANZCR and the DIAS Advisory Committee consult each other on the best distribution of efforts to achieve the aims in the previous two recommendations, and that they work together to develop a programme for communicating any changes to radiologists and diagnostic imaging practices.
18. That FMIG review their compliance with the DIAS Practice Accreditation Standards, in particular Standard 2.1.
19. That the Commonwealth Minister for Health undertake an audit of all Australian accredited diagnostic imaging practices regarding their compliance with DIAS Practice Accreditation Standard 2.1.
20. That the Commonwealth Minister for Health produce and promulgate standard forms for referrals to diagnostic imaging practices, ensuring that referrals include clinical information and effective contact information, and that the Minister consider whether measures should be taken to mandate the use of such forms.
the workplace health industry
21. That the Australian Competition and Consumer Commission consider whether enforcement action is appropriate against Priority Care Health Solutions, MRI Now or related corporate entities for unconscionable, misleading and/or deceptive conduct in their businesses which:
(a) gave clients the impression that the business directly employs medical practitioners, when it does not; and
(b) gave the impression to diagnostic imaging practices that a medical practitioner has reviewed a patient before requesting a scan, when they have not.
22. That the Royal Australian College of General Practitioners (RACGP) and the Australasian Faculty of Occupational & Environmental Medicine (AFOEM) of the Royal Australasian College of Physicians prepare a joint position statement on whether practitioners engaged in workplace health have different obligations to ‘clients’ or ‘candidates’, for whom they are undertaking a limited review of information, than they do toward their ‘patients’, as was suggested by Dr Saad.
23. That the RACGP and the AFOEM prepare a joint position statement on the appropriateness of a practitioner authorising, or otherwise allowing, their signature to be used in referring individuals (whether ‘patients’, ‘clients’ or ‘candidates’) for tests when neither the patient, nor any information specific to the patient, has been reviewed.
emergency services
24. That Ambulance Victoria (AV) issue a practice advisory highlighting that adrenaline be administered as soon as practicable to patients who have acutely deteriorated within a short time of receiving radiological contrast at a radiology clinic.
25. That AV issue a practice advisory highlighting the possibility of beta-blocking medication being present in a patient experiencing anaphylaxis to radiological contrast whilst undergoing cardiac CT, and that consideration should be given to administering glucagon in these circumstances if the patient is unresponsive to adrenaline. .
