Law and Order
State Coroner finds Ike Zerk would be alive today if specialist cardiologist Dr Phillip Adams had made follow-up call
IKE Zerk would be alive today if his cardiologist had made a simple follow-up phone call to an interstate surgical team, an inquest has found.
IKE Zerk would be alive today if his cardiologist had made a simple follow-up phone call to an interstate surgical team.
State Coroner Mark Johns has found
SA cardiologist Dr Phillip Adams failed to check if the surgical team in Melbourne had received Ike’s test results, which would have put him on the operation list.
The 14-year-old was in urgent need of a replacement heart valve.
Dr Adams sent the test results by mail but the Melbourne team never received them so he was not operated on.
He died on a Barossa football field in March 2015 — six months later after the vital tests.
His test results showed he should have been operated on within three months.
On Friday, lawyer Claire O’Connor spoke for Ike’s parents Jordan and Megan Zerk outside the Coroner’s Court, saying they were happy with Mr Johns’ findings.
“The mind-blowing issue that’s at the centre of this inquest is that something as simple as a follow-up phone call would have seen Ike with a surgical team and he would have been operated on,” she said.
“He would have been alive today — that’s the absolute tragedy of this case.
“The main finding is that Ike’s death was foreseeable and preventable and it was the failure of Dr Adams to provide proper care for Ike in three ways that have led to his death.”
Mr Johns found Dr Adams failed to call the Melbourne team to check they had received his referral letter and test results and advise his parents that Ike should have been on an operation list and living a quiet life.
“He failed to ensure that the September 2014 correspondence was indeed received by the Melbourne team,” he said in his findings.
“That was a part of his care for Ike and a part of his duty as a cardiologist.”
“Had the report made its way to Melbourne, Ike’s parents would have become aware of the need to prepare for surgery.
“It is quite clear from their evidence and their high level of concern for Ike’s wellbeing that they themselves would have made the decision to cease Ike’s sport immediately.
“He would not have been at football practice in March 2015.
“Indeed, he would likely have had his surgery well before then.”
Mr Johns also found the Melbourne team did not receive an earlier letter by Dr Adams in December 2013, which should have raised alarm bells about the way in which he sent future information.
“In those circumstances it was incumbent upon him to exercise great caution with his subsequent correspondence,” he said.
“It is absurd and unacceptable that the life of an otherwise healthy 14 year old should be put at risk by reliance upon the ordinary mail service.”
Mr Johns made two recommendations:
THE Health Minister speak with interstate counterparts about fixing guidelines so there is a threshold for surgical intervention for paediatric patients with a heart condition like Ike’s, and;
A MANDATORY system for all cardiologists treating paediatric patients to lodge information with the Women’s and Children’s Hospital.
“The Women’s and Children’s Hospital should then be responsible for forwarding the reports to the team in Melbourne when that is required,” he said.
“Short of recommending that a paediatric cardiac surgical service be commenced in Adelaide, nothing less than the supervision of the safe transmission of crucial data by the Women’s and Children’s Hospital can suffice.”
In a statement, Health Minister Peter Malinauskas said: “I take seriously all recommendations made by the Coroner.
“I will look at the report in detail and consider the findings he has made.”
Opposition health spokesman Stephen Wade said the Liberals would not commit to an SA paediatric cardiac surgery service.
, the body loves homeostasis
