Pressure on emergency departments and ambulances at peak times causes delays that may cost vulnerable people their lives, the Acting State Coroner has warned.
Evelyn Vicker gave the warning yesterday in findings into the September 2009 death of Melissa Ann Nielson, 24, who should have been assessed properly within 30 minutes of arriving at Royal Perth Hospital.
Ms Vicker found communication errors aligned with delays from pressure on health services led to a "catastrophic outcome" for Miss Nielson, her family and the people who cared for her.
"There is no doubt the pressure on emergency departments and St John Ambulance services at times of peak usage causes delays in appropriate clinical assessment which may cost lives for patients as vulnerable as the deceased," she said.
Miss Nielson, who had a complex medical history, went to Joondalup Health Campus with severe skin lesions which doctors there were unable to diagnose.
Because of her accelerating condition they requested an urgent transfer to RPH for a dermatological review.
Miss Nielson arrived at RPH soon after midnight and about 12.10am a triage nurse gave her a score of three, which meant she should have been seen within 30 minutes.
She was found unresponsive and not breathing about 12.50am and died in intensive care about two weeks later.
Ms Vicker said the main features that needed addressing in Miss Nielson's treatment and management were delays between appropriate assessment and decision-making and the lack of communication of information in a way that ensured it was taken into account through her transfer between hospitals and before she was assessed in RPH's emergency department.
RPH executive director Professor Frank Daly said the hospital was considering the recommendations and working on how to implement them.
The recommendations included RPH emergency considers "smart computers" to integrate entries to its system of a patient's files.
Ms Vicker also suggested that when the ED was over capacity and delays were possible, it introduce "vital sign observations" at triage, rather than solely of airway, breathing and circulation.