An ACT coroner, Ken Archer, has found the 2016 death of Canberra man Maarouf El-Cheikh at Calvary Hospital occurred after he received “sub-optimal” care that did not give him a “chance of survival”

The coroner found Mr El-Cheikh died in the hospital’s emergency department amid “errant clinical judgements”. These findings detailed how Mr El-Cheikh went into cardiac arrest and could not be revived with his cause of death – streptococcus pneumonia septicaemia.

The Coroner detailed systematic failures at the hospital including inadequate staffing, poor sepsis treatment, unwarranted restrictions on access to infectious disease physicians and a culture that stops staff from escalating patient care issues.

The full ABC News story can be access here.

The coroner acknowledged that the hospital had made some changes after the death, including an updated sepsis protocol, but he apologised to Mr El-Cheikh’s family for the delay in the coronial and ‘poor levels of communication’ from the court.

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