A beloved Melbourne mum never came home from work after she had a deadly allergic reaction to a dye for an “unnecessary and invasive” test.
Peta Hickey was a mum of two and successful executive when she went for a heart check her employer organised at a Moonee Ponds radiology clinic on May 1, 2019.
But after the 43-year old was injected with contrast dye for the CT scan, she became nauseous and short of breath. She was rushed to hospital but died eight days later on May 9.
An inquest was held into her death and in his findings on Monday, Coroner Simon McGregor was critical of the “unnecessary” test, the clinical judgment of doctors and businesses involved.
It was a long fight for justice for Ms Hickey’s partner Richard, who said she should have been helping their children get ready for school and rehearse lines for a musical.
“Instead we prepare for those milestones and another Christmas without Peta as we’ve done every day since she went to work two-and-a-half years ago and didn’t come home after having an invasive and unnecessary angiogram test,” an emotional Mr Hickey said outside the Coroners Court of Victoria.
He wants an apology from those involved, while his lawyer Kathryn Booth of Maurice Blackburn said legal action against them was being planned.
“(The finding) puts everybody on notice that invasive testing for asymptomatic patients is a risky business,” Ms Booth said.
In his findings, the coroner lashed the medical industry putting “profits over patients” and said the test was “unnecessary and proved nothing”, with an autopsy confirming the mum had no heart issues.
“Peta died as a result of substandard clinical judgment from doctors at the beginning and the end of this program, combined with a misalignment of incentives among the various business entities that facilitated the process,” Mr McGregor said.
“It may be somewhat of an oversimplification but the snapshot provided by this inquest has revealed an industry putting profits over patients.”
The CT scan was part of a heart check program her employer Programmed introduced for managers after a staffer had a non-fatal cardiac arrest while working overseas.
To facilitate the program, the labour hire firm went to Priority Health Care Solutions, which outsourced “bulk medical assessments” from another company called Jobfit.
That company employed Doumit Saad, whose electronic signature was on the referral form for Ms Hickey.
But he never met her and there were no clinical notes attached to his referral, the coroner said.
Medical imaging service MRI Now used those referrals to send Ms Hickey to Future Medical Imaging Group where radiologist Gavin Tseng was to carry out the scan.
Mr McGregor directed the Australian Health Practitioner Regulation Agency be notified the practices of both the doctors involved were “insufficient and unsafe”.
The coroner said Dr Saad’s actions were unsafe in allowing his electronic signature to be used for patients he had not reviewed and he failed to stop the program after he found out his signature was being used.
The radiologist who injected the dye, Dr Tseng, failed to recognise Ms Hickey’s reaction, didn’t administer adrenaline and carried out another CT scan just days after the severe reaction.
The coroner noted Dr Tseng had undergone additional training and his failure was likely because of a lack of training and shock.
He also called for federal Health Minister Greg Hunt to audit the conduct of Australian accredited diagnostic imaging practices for compliance and wants a review of appropriate screening for CT scans and other invasive cardiac tests.
The nation’s consumer watchdog was also asked to consider taking action against Priority Care Health Solutions and MRI Now for unconscionable, misleading or deceptive conduct on two grounds including giving the impression that a medical practitioner had reviewed a patient before requesting a scan, when it had not.
The coroner found the conduct of Ms Hickey’s employer, the company used to facilitate and co-ordinate the heart check program and the doctors “causally contributed to Peta’s death”.