Royal Adelaide Hospital emergency department chief tells inquest access block causes 'unrelenting' ramping

Bernard Anthony Skeffington died after being ramped for five hours. (Supplied)

The co-director of the Royal Adelaide Hospital (RAH) emergency department has described ramping as "unrelenting" at a coronial inquest into three unrelated deaths affected by ramping.

Deputy State Coroner Ian White is investigating the deaths of Anna Vincenza Panella, 76, in April 2019, Bernard Anthony Skeffington, 89, in September 2021 and Graham Henry Jessett, 64, in March 2022.

Each died after being ramped outside emergency departments at either the RAH or Flinders Medical Centre.

Dr Maria Katrina Romualdez was not involved in the RAH's treatment of Ms Panella, but was acting director of the hospital's emergency department at the time of Mr Skeffington's death.

She provided data to the inquest showing there were 87 patients in the ED at the time of Mr Skeffington's presentation at 2:18pm, 62 of which presented between midday and 3pm.

Dr Romualdez told the court about the effects ramping has on ED staff.

"We deal with the stress of not knowing how sick our patients are that are on the ramp that can't get in, or who in the waiting room and can't get in," she said.

"The stress of dealing with the unknown of that takes a toll on staff."

"[Ramping's] a phenomenon that we come on to every day. It's unrelenting."

Dr Romauldez also said the pressure has an effect on personal lives, and has caused many staff to leave the department.

"We have seen a significant turnover in personnel, both nursing and medical, especially in the last few years," she said.

Access block named key ramping contributor

Mr Skeffington was one of a cluster of deaths which underwent a team-based review at the RAH, all of which were affected by ramping and access block at the RAH.

Dr Romualdez said access block and ramping are both system-wide issues.

"There was a lot of discussion regarding next steps when it came to how to address access block as a hospital and as a system," she said.

Access block is when patients are unable to be admitted to other wards within the hospital, and therefore moved out of the ED.

Dr Romualdez said it was the root cause of ramping.

"When we make a decision that [patients] need admission into hospital, unfortunately there then is a large delay into them leaving the ED into the ward, and that creates blockage in the ED," she said.

Dr Romualdez said mental health patients were a large contributor to access block in the RAH, with up to a quarter of ED presentations being related to mental health.

"It appears that the limiting factor is the availability of in-patient beds for mental health patients," she said.

"Our bed base for mental health patients does not meet the demand for what we receive."

Dr Romualdez was acting director of the emergency department when the RAH switched to its current location in 2017.

She said access block, and therefore ramping, significantly increased after the move to the new hospital premises.

"I certainly recall the frequency of external triage increasing, and then it exponentially increased along with the move to the new hospital," Dr Romualdez said.

"There were an increasing inability for our admitted patients to access inpatient beds, and that led to many hours of ramping."

Current health crisis an extreme result of access block

Counsel assisting the coroner Darren Evans raised the current code yellow emergency declared for the state's health system last month.

Dr Romualdez said that the code yellow has allowed the emergency department to better offload inpatients to other wards within the hospital, therefore freeing up beds and lowering ramping.

"Around the beginning of the state-wide code yellow, I would say that it was seemingly an unprecedented or a really severe degree of access block," she said.

"I think it has made an impact on the levels of access block that we were seeing prior to the instatement of the code yellow."

But Dr Romualdez said the internal emergency cannot be sustained, and referenced people who were waiting on essential elective surgeries to resume.

"I'm concerned it's not a sustainable state to be in, and it's unsustainable to continually cancel elective surgery."

The inquest continues.