Stephen Guy Bruinger died at the RHH on January 16, 2017 from a cerebral haemorrhage. 

The 62-year-old’s death was not reported to the coroner for eight days. 

A father of three, Mr Bruinger was initially misdiagnosed when he presented at the emergency department, and was subsequently given inappropriate medication. 

In a report to the coroner, ED director Dr Emma Huckerby wrote that extreme overcrowding prevented Mr Bruinger from receiving, for a period of eight hours, the appropriate level of monitoring that his condition required. 

“This patient should have been allocated a monitored cubicle in the main ED to observe his vital signs continuously over time in order to establish the pattern of his episodes of vital sign abnormalities which included episodes of severe hypertension,” Dr Huckerby said.

“Due to extreme ED overcrowding there was no capacity for this to occur for more than eight hours – including after he was discovered to have a NSTEMI.

“Patient experienced an intracerebral bleed, was admitted to ICU and has subsequently died.

“Hourly audits of the ED capacity over this time period show that at all times there was ambulance ramping, no availability of acute ED cubicles and for seven hours there was access to zero or one resuscitation cubicles.”

In handing down his findings, coroner Rod Chandler said while the level of demand in the emergency department did not directly cause Mr Bruinger’s death, it was the responsibility of hospital management to investigate the situation. 

“A matter of real concern arising from this investigation is the report of Dr Huckerby and her opinion that the overcrowding in her ED prevented Mr Bruinger from receiving, for a period of eight hours, the appropriate level of monitoring which his condition required,” coroner Chandler said. 

“Whilst the incapacity to better monitor Mr Bruinger was not, in the circumstances of his case, a factor causative of his death, the state of affairs as described by Dr Huckerby had the prospect of seriously compromising patient safety. 

“It also must have been particularly difficult and stressful for the medical and ancillary staff.

“In this circumstance it behoves those persons responsible for the management of the RHH to investigate the situation and to adopt changes which prevents or at least significantly reduces the prospect of its repetition.”

The Tasmanian Health Service was contacted for comment. 

A spokesman said: “In noting the coroner’s findings, the THS also notes the coroner found that levels of demand in the emergency department were not causative of the Mr Bruinger’s death.”

Coroner Chandler did not make any recommendations. 

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