Understaffing and healthcare workers stretched beyond capacity has had fatal consequences. This is the hospital crisis in Australia.
Every Friday night, Aswath Chavittupara and Prasitha Sasidharan and their four kids would pull their mattresses onto the floor of their Perth home for a big family sleepover tradition they called “carpet room night”.
April 1, 2021, was a Thursday, but since it was the start of the school holidays they had carpet room night early. Siblings Amrita, Aishwarya, Aaryan and Adithya were in high spirits and the family decided to walk to their local ice-cream parlour as a special treat.
Aishwarya, their second born, had recently won the school talent quest with a magic show she’d performed with her big sister Amrita, and the two were happily hatching a plan to start a YouTube magic channel.
The sisters were “always laughing together” her family said. There was no hint anything was amiss. Aishwarya, seven, woke up early on Friday morning with a headache. Prasitha gave her Panadol, but she began vomiting and by the next day she was sore and weak. Aishwarya’s hands were cold, but her forehead was hot.
Concerned, her parents rushed her to Perth Children’s Hospital (PCH). They passed two ominous signs as they entered the Emergency Department. One said the average wait time was four to six hours, the other warned that abusive behaviour would not be tolerated.
Emergency staff had been enduring an escalating level of aggression from parents as waiting times blew out, WA Deputy State Coroner Sarah Linton later reported, and the children’s hospital had a security guard on staff. It was into this tense environment that Aswath and Prasitha brought their “happy and very loved little girl”.
Aishwarya was triaged as non-urgent, but her parents could see something was seriously wrong. Over the coming hour they would repeatedly try to get their daughter the urgent care she needed. Ninety minutes after arriving, Aishwarya told her parents she “felt as though she was falling”. Her speech became faint, and Prasitha knew they couldn’t wait any longer.
As she later told the WA Coroner’s Court, she begged for someone to look at Aishwarya. It was too late. She succumbed to fulminant sepsis. For two years, Aswath and Prasitha have fought for answers and change. They wanted to know how their vibrant little girl could die waiting for care in a state-of-the-art public hospital, and they wanted to ensure no parent would ever have to suffer through what they endured.
“She was full of life, always happy to be around, always positive. Our daughter had big dreams in life and always dreamed of becoming a teacher. She was, in fact, a teacher for her younger brothers,” they said in a submission to the coroner.
The inquest uncovered a series of missed opportunities and interrupted care in an emergency department where nurses had voiced their “grave safety concerns” that staffing problems made them anxious that they “could not deliver adequate care to all patients”.
The coroner identified significant changes the government could make to increase hospital safety. “There is no point in having a state-of-the-art facility if the staff working within it are stretched beyond capacity,” she said.
Another grieving family, whose members are still waiting for answers after losing their own daughter, agree much more needs to be done. “We think there’s a massive crisis in the WA healthcare system,” mother Kellie Hunter tells The Weekly.
Kellie and Kim Hunter’s daughter, Ashleigh, died of a meningococcal W infection at Royal Perth Hospital (RPH) on December 27, 2019, about an hour after she was brought in by ambulance. Like Aishwarya’s family, Kellie and Kim lobbied the coroner to examine whether failures in the health system robbed their daughter of her chance at survival.
Ashleigh arrived at RPH and was triaged at ATS 3, meaning she should be treated within 30 minutes. She waited almost double that time. Ashleigh’s last words were, “It really hurts, please help me.” Her parents say overcrowding and bed block robbed their daughter of any chance of survival and caused her to experience an extremely painful and traumatic death.
What is ambulance ramping?
The ambulance that Ashleigh arrived in was ramped for eight to 13 minutes outside the Emergency Department, the coroner’s court heard last November. Ramping occurs when patients are cared for by paramedics in the ambulance or hospital waiting areas until there is a free Emergency Department (ED) bed and available staff.
The coroner’s court heard that ramping for the time period Ashleigh had waited was normal, but the Australian Medical Association says ramping for any length of time “is the symptom of a sick system and a danger to public health”.
“Patient care absolutely is being compromised because of the overcrowding in EDs,” Kim says. “We accept that the odds of Ashleigh’s long-term survival were low, but it was the inhumane way in which she was allowed to die that we will never forgive.
“Our dearly loved daughter, despite being practically on the doorstep of the ED at one of Perth’s leading tertiary hospitals, died in extreme distress.” Ashleigh’s parents emphasise the problems are systemic, not down to the actions of frontline workers.
“We know Perth hospitals are staffed with highly qualified professionals,” says Kellie. “But this is worth nothing when patients cannot have access to that care.”
While the Hunter family waited for answers, the situation grew worse. One month before Coroner Linton delivered her scathing report in Aishwarya’s matter, WA had posted its worst January on record for ambulance ramping.
For the first month of 2023, WA ambulances were ramped for 4700 hours, an increase of 26 per cent on January 2022, according to data released by the Australian Medical Association’s WA office.
A shortage of healthcare workers in Australia
“The fundamental driver of all of these problems is inadequate capacity in the system,” says the AMA’s WA president, Dr Mark Duncan-Smith. He points to underfunding, a culture of cost-cutting and a lack of respect for frontline workers as the roots of this complex problem.
“International studies have shown that the most efficient hospital occupancy is 85 per cent. Once you go over 90 per cent, your rates of bed block, cancellation of elective surgery [and] death all go up. WA hospitals routinely run at 100 per cent occupied and sometimes over 100 per cent occupied,” Dr Duncan-Smith tells The Weekly.
He stresses that WA is the worst performing state in the country, but says the problems exist across the board. “It is a nationwide issue, there’s no doubt about that.” And the causes stretch well beyond the hospital system.
A recent AMA report points out that ambulance ramping and logjams at the admission end of hospital care relate directly to a lack of safe spaces into which hospitals can discharge patients. Many patients remain in hospital long after doctors have deemed them ready for release because there are no available beds in aged or disability care to which they can transition.
“‘Exit block’ is a symptom of a healthcare system that is struggling to meet community demand for health and social services. However, it has a significant impact on hospital logjams,” the report concludes.
“Exit block means there are less beds for inpatient services, which ultimately results in increased waiting times for ambulance services, emergency department services and essential elective surgeries.”
Another AMA study, released in January this year, analysed data from 201 public hospitals around the country and found that only three of them were delivering care within recommended timeframes.
“We’ve been functioning in disaster-like conditions for years now,” says Australian College of Nursing CEO Adjunct Professor Kylie Ward. She speaks with The Weekly at length about the pressure nurses were under even before COVID pushed an already stressed workforce to breaking point.
“It has just been one crisis after another in a system that was already feeling the pressure,” Professor Ward says. “No matter how hard you work, how much you give, there’s always someone who needs more – and the waiting list full of people, or waiting rooms, or beds or services – it just seems endless.”
With that comes relentless exhaustion. “To be a frontline worker, I’d love to say there was a pride, but I think there’s more of an exhaustion and perhaps guilt. There’s an enormous amount of moral injury, feeling like you can never do enough, feeling a lack of value.”
Burnout in healthcare workers
Professor Ward has personally felt the effects of burnout, reporting how as a nurse she would work 18- and 20-hour days back-to-back. In her role as CEO of the ACN, she sometimes wakes up to between 80 and 100 text messages from nurses around the country reporting on the conditions where they’re working.Sometimes, she says, they’re working with 15 staff members down.
One NSW nurse, Claire*, says she feels overworked most days. “Many of my colleagues feel there is no end in sight, that the activity is just getting higher and people are less patient,” she explains.
As a 40-year veteran of hospital care, and an Emergency Department nurse, Claire is used to working in stressful conditions, but says the compounding effect the pandemic had on an already struggling sector has led to a deep exhaustion, and the loss of staff. Hospital activity has outpaced future planning.
“Colleagues in Maitland, for example, they’re planning for 2027, but the activity has already got there. It’s not going to be future-proofed because the activity has grown,” she says. The demands of COVID infection control mean frontline workers have so much more to do.
“You can’t get people to work and when you do get them, are they the right [people]? They’re just plugging holes rather than getting people with the skill.
Perhaps most concerning is that frontline workers, and in particular nurses, are bearing the brunt of the public’s frustration with an overstretched system. Towards the end of 2021, occupational violence increased.
“I had nurses call me to say that, on their way home, they were spat on. People became very scared and attacked frontline workers,” Professor Ward explains, adding that nurses endure both verbal abuse and threats: “‘I’m going to follow you home.’ Arms are being grabbed.”
Claire says patients and family members are becoming more anxious and stressed because of the pressure on hospitals, and they’re taking it out on nurses. “We understand,” she insists, “that they’re heightened in their anxiety, but sometimes when you’ve had that [aggression] happen to you 20 times a day, that constant battering does take its toll.”
“How much can you just keep giving and where do you find that before you end up empty?” Professor Ward adds.
More than one-quarter of primary healthcare nurses are planning to leave their jobs in the coming two to five years. Four in five nurses at Perth Children’s Hospital say they feel exhausted at work (80.4 per cent) and an overwhelming majority (86.7 per cent) of PCH nurses say they feel stressed at work, according to a survey of more than 1000 nurses by the Australian Primary Health Care Nurses Association.
Dr Duncan-Smith says nurses are already leaving the industry in WA. “For every 10 nurses who have been recruited in the last year, four have resigned. This indicates a high-stress, poor work environment.”
Professor Ward says the number of people enrolling in nursing in university has decreased for the first time in decades. She’s also worried that the young nurses who are coming up through the ranks won’t have enough mentors and leaders to help them develop their skills.
“That whole band of knowledge and wisdom and expertise of senior nurses that would have always been there to guide graduate and early-career nurses is just evaporating. You cannot staff a hospital with graduates.”
Federal funding for hospitals
The tragic losses of Aishwarya and Ashleigh, and the testimonies from nurses outlined above, are a window into what the Australian Medical Association says is a crisis in our hospitals. It’s campaigning for more funding at a federal level.
AMA president Professor Steve Robson says underinvestment and outdated funding models are its biggest concerns. “It’s led to overworked and burnt-out staff – our first responders and the people we need most to look after us and our loved ones.”
And that includes our doctors. Data shows doctors are working unsafe and unsustainable hours. The most recent safety audit, from 2016, found half of all doctors work an average of 78 hours per week. One doctor reported a work week of 118 hours.
“It should be clear to anyone following the news, anyone waiting for surgery, anyone who can’t get in to see a specialist, anyone who ends up waiting for hours in the back of an ambulance outside a hospital – it should be clear, in fact, to everyone – that our hospitals are at crisis point,” Professor Robson stresses.
After examining the tragic death of Aishwarya, the first recommendation Coroner Linton made was that nurse-to-patient ratios are needed in WA, with minimum ratios to be put in place in emergency departments as a matter of priority.
“Patient safety should not wait for the outcome of negotiations,” she said. She also recommended the introduction of a specialist resuscitation team and improved triage procedures at PCH and better health department funding for electronic record keeping.
She noted the staff on duty on the night that Aishwarya died have likely reflected on things they would do differently, but she was sympathetic to the situation they had been placed in. The accounts of how staff disregarded the pleas for help from Aishwarya’s parents, as she lay on a waiting room couch with her head on her mother’s lap, are hard to read.
But there is a broader context. The Emergency Department was busy. Staff were being called away to help with resuscitations. Crucially, the ED staff had feared that a tragedy like this would happen and had tried to prevent it.
On March 9, 2021, a mere three weeks before Aishwarya fell ill, a nurse who worked in the PCH ED wrote to the head of their union “raising their grave safety concerns and their anxiety that they could not deliver adequate care to all patients”, Coroner Linton’s report states. The letter made it clear that nursing staff wanted their fears to be heard by the executive, but that meetings kept being cancelled.
“The alarm that patient safety would be compromised had been sounded and the staff were left to carry on as best they could until some help arrived,” Coroner Linton said. The status quo is “frustrating and demoralising”, Dr Duncan-Smith tells The Weekly.
“What you’ve got from the frontline healthcare workers, the doctors and the nurses, going up the bureaucracy chain is messages like, ‘The emergency department is unsafe. Someone is going to die unnecessarily and here is the solution to fix it, which costs money.’ Unfortunately, health in WA has a culture, coming from above, of budget and cost-cutting. Therefore, you get this grating of cogs somewhere in the middle management.
“It’s incredibly stressful. It’s incredibly anxiety-generating. It’s incredibly frustrating. Hence the high rates of burnout, the high staff turnover, the really poor satisfaction with the job and their ability to deliver safe and quality healthcare.”
The WA government responded to the coroner’s report with a commitment to do more. WA Health said it had already made changes, including increasing Emergency Department staff and fast-tracking ratios. However, Health Minister Amber-Jade Sanderson was forced to backtrack after stating that recommended special resuscitation teams were in place, when they weren’t.
AMA WA remains frustrated with what it sees as a lack of local funding, a sentiment that is echoed by the national AMA. Dr Duncan-Smith says the government just doesn’t get it. “Sometimes, I wonder whether I’m sitting in an episode of Utopia,” he says.
The AMA is calling on both state and federal governments to release adequate funding to improve hospital performance, expand staffing and capacity, fund more out-of-hospital care and move towards 50-50 federal and state funding, with no cap on funding growth.
Aishwarya’s parents hope the government will adopt every recommendation in Coroner Linton’s report. But neither that, nor the birth of a new baby girl last September, will lessen the pain of losing Aishwarya.
“Every mother should be cherishing their children’s achievements and be there to share their children’s happiness,” Prasitha said, “but I am holding my daughter’s death certificate.”
*Claire’s name has been changed to protect her privacy.