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Coroner links delayed heart surgery to systemic overload at Adelaide hospital

A coroner concluded that Petar Josipovic's death in September 2023 was likely avoidable had his cardiac operation not been postponed, citing an overburdened health system.

Petar Josipovic, a 62-year-old patient, passed away on September 14, 2023, after his high-priority cardiac surgery was delayed multiple times at the Royal Adelaide Hospital. The coroner determined that the operation, if completed by August 22, 2023, would likely have prevented his death, but systemic strain meant the chance never arose. While no ill-will was found in the cancellation decisions, the inquiry noted a wider cohort of patients at risk due to an overworked system.

The delay increased both the risk to Josipovic’s life and the state’s financial burden, with emergency care costs rising from under $75,000 to $250,000. Recommendations were made to Health Minister Blair Boyer for an external review of referral pathways, theatre lists, and cancellation policies, as well as clearer patient communication guidelines. The coroner expressed condolences to the family, acknowledging the son Nick Josipovic’s testimony throughout the hearing.

Why it matters

It exposes how hospital capacity limits can turn treatable conditions into fatal outcomes, prompting calls for systemic reform.

In this story

cardiac surgerysystemic failingsoverworked health systemsurgical delaysexternal reviewpatient safetyhealth ministercost of care