Coroner finds delayed surgery contributed to death amid strained SA health system

A man, who died after his high-priority cardiac surgery was delayed, could have survived if the operation occurred sooner — but South Australia's overworked health system meant it "might have come at the cost of the chance of survival of another patient", a coroner has found.

Petar Josipovic, 62, died in the Royal Adelaide Hospital (RAH) on September 14, 2023, after he was placed on a waiting list for category one cardiac surgery in June that year — an operation which should have occurred within 30 days.

During the inquest last year, the court heard Mr Josipovic's surgery was scheduled 54 days later, on August 14, 2023, but was rescheduled multiple times.

He became unwell on August 24 and was rushed to hospital where he suffered a cardiac arrest.

He had successful emergency surgery early the next morning, but died from complications three weeks later.

State Coroner David Whittle today handed down his findings, and said that, on the balance of probabilities, Mr Josipovic's death "would have been unlikely if surgery was performed" on or before August 22, 2023.

However, he said the "opportunity to perform it earlier did not genuinely arise".

Mr Whittle said he was impressed with the witnesses who gave evidence and did "not make any finding that decisions that led to the cancellations were the result of ill-will or lack of due care".

He noted, however, that there was "a wider cohort of concerning patients" at the time.

He said had Mr Josipovic's surgery gone ahead as scheduled on August 14, 2023, his "chance of survival was high".

"Of course, I observe that proceeding with the surgery on that day might have come at the cost of the chance of survival of another patient and that difficult decisions were made," he said.

"I am in the end unable to conclude that there was a genuine opportunity to make a different decision."

Delay 'exponentially increased risk'

During the inquest, the court heard Mr Josipovic's son, Nick Josipovic, had written to the coroner on the day his father died, raising concerns about delays to his surgery.

He had told the inquest he had pleaded for his father's surgery to occur in the scheduled date, because his family "had great concerns" he would not survive.

In his findings, Mr Whittle said Mr Josipovic did not go to the emergency department on earlier occasions when he was invited to, which would "reasonably give clinicians a sense of ease about the seriousness of his deterioration and also prevented the physical examination of his condition that was necessary to fully appreciate his risk".

He said the inquest had been told that Mr Josipovic's surgery would have cost less than $75,000 if it occurred electively, but the ultimate cost of his care following his emergency surgery admission was $250,000.

Mr Whittle noted there had been several improvements to the manner of delivery of cardiothoracic services at the RAH since Mr Josipovic's death, and noted he had heard evidence there was now "better oversight of waiting lists" at the hospital.

But, he said even with other improvements that had been made, including increased operating capacity, "more can be done".

He made two recommendations to Health Minister Blair Boyer, including that an external review be conducted to consider matters including the referral process, clinic capacity, the costs and benefits of an additional theatre list and surgical cancellations.

Mr Whittle also recommended clear guidelines be developed about the information and advice to be given to patients awaiting cardiothoracic surgery who report clinical deterioration.

Mr Whittle also expressed his sincere condolences to Mr Josipovic's family, noting his son Nick had given evidence and attended the hearing each day.

An SA Health spokesperson shared their condolences to Mr Josipovic's family, and said it would consider the coroner's recommendations.