Background
In 2019, Peta Hickey, a 43-year-old woman with no medical history of cardiac problems, agreed to take part in a voluntary corporate heart check program her employer introduced for its senior executives. The program involved participants undergoing a CT coronary angiogram (heart scan) which included the administration of an IV contrast dye.
Dr Doumit Saad (Dr Saad) was responsible for reviewing and interpreting CT scan test results for the participants (including Ms Hickey). The form used to book Ms Hickey for the heart scan included a referral form bearing Dr Saad’s name as the referring doctor and Dr Saad’s electronic signature. The referral did not include any clinical notes, and Dr Saad did not have any involvement in Ms Hickey’s care prior to the heart scan. In short, Ms Hickey was never assessed for the heart scan nor had risks or alteratives properly explained.
On 1 May 2019, Ms Hickey attended on radiologist, Dr Gavin Tseng (Dr Tseng), for the heart scan. Prior to undergoing the heart scan, she was asked to complete a CT coronary angiogram questionnaire, which she did.
After Dr Tseng administered the IV contrast dye, Ms Hickey suffered an allergic reaction. She was transported to the Royal Melbourne Hospital and admitted to the Emergency Department and then the intensive care unit. She did not regain consciousness and died eight days later, on 9 May 2019.
An autopsy revealed her cause of death was multisystem organ failure and hypoxic/ischaemic encephalopathy, and an anaphylactic reaction to CT contrast medium. The post-mortem examination also confirmed Ms Hickey had a normal heart and coronary artery and found no evidence suggestive of cardiovascular disease.
Outcome
The coroner was critical of the doctors (and various business entities) involved in the heart check program and commented at [27] that Ms Hickey:
‘…died as a result of substandard clinical judgment 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’.
Dr Saad’s referral for Ms Hickey’s heart scan was found to be ‘invalid’, as it lacked any clinical information or indication for the scan. As for Dr Tseng, it was not appropriate for him to proceed with the heart scan in the absence of any clinical justification on the face of the referral or obtained from Dr Saad as the referring doctor. He should have recognised Ms Hickey’s symptoms as a contrast reaction and administered adrenaline as soon as possible. Her reaction to the contrast dye was poorly managed by Dr Tseng, and there was nothing the other radiology staff or emergency services personnel could do to reverse the reaction, despite their timely attendances.
The Coroner commented that both Dr Saad and Dr Tseng ‘departed from normal professional practices’ and directed that Ahpra be notified that their practices were ‘insufficient and unsafe’.
Recommendations
A number of recommendations were made connected with Ms Hickey’s death, including:
- That the Royal Australian and New Zealand College of Radiologists (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.
- RANZCR update its standards and guidelines regarding both clinical request 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.
- That the Royal Australian College of General Practitioners and the Australasian Faculty of Occupational & Environmental Medicine 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.
The Coroner’s full findings are available here.
