A report from the Queensland Health Ombudsman has revealed serious systemic failures at Robina Hospital, which contributed to the tragic death of Stewart Kelly, a 45-year-old man with autism. Kelly died from starvation and dehydration during a 33-day hospital stay in 2022, despite being admitted for non-critical reasons. His mother, Ann Jeffery, had raised concerns about his care, which went largely ignored.
Kelly was admitted to Robina Hospital after experiencing significant weight loss due to a refusal to eat. His family expected he would receive appropriate treatment, including fluids and psychiatric support, yet neither was provided. The incident sparked an investigation after a report aired on A Current Affair in December 2022, resulting in a lengthy inquiry by the Office of the Health Ombudsman (OHO).
Ann Jeffery expressed her devastation over the situation, stating, “My life has disintegrated. I’ve got no joy left in my life, and the stress of waiting for answers has been devastating.” The OHO’s findings highlighted several failures across multiple departments, including a lack of recognition for the needs of patients with neurodevelopmental disorders and poor communication between medical teams.
In a particularly troubling aspect of the case, Ann Jeffery was prevented from initiating a Ryan’s Rule review, a mechanism designed to empower families to advocate for better care. The report noted that while she was aware of the rule, she was not provided with proper information on how to activate it. This lack of communication was termed a “systemic failure” by the OHO, which pointed out that her advocacy was essential yet overlooked.
The report has led to calls for accountability from Kelly’s family. His sister-in-law, Shelley Jeffery, stated that some hospital staff “completely failed” him and expressed concern that similar incidents could happen to others in the future. The chief executive of Gold Coast Health, Ron Calvert, declined to comment further but acknowledged the significant failings in Kelly’s care. A spokesperson for the organization noted that the staff involved had been profoundly affected by the incident and were undergoing additional training to prevent future occurrences.
Gold Coast Health has accepted all 18 recommendations made by the OHO, including improving awareness and implementation of Ryan’s Rule. A spokesperson stated that they are committed to ensuring such an incident does not happen again and have established a High Complexity Cognitive Care Service to address the needs of patients with complex conditions.
Despite the hospital’s assertions, the family remains unconvinced that Kelly’s case was “exceptionally rare.” Shelley Jeffery countered that many individuals with mental health issues, such as those who refuse to eat, represent a common challenge rather than an exceptional situation.
Ann Jeffery believes that a coroner’s inquest is necessary to prevent future systemic failures in healthcare. She stated, “We will get justice for Stewart.” In response to the family’s concerns, Queensland Health Minister Tim Nicholls expressed his sympathies and promised assistance in expediting the coroner’s report, acknowledging the distress caused by the delays in the investigation process.
The tragic death of Stewart Kelly has raised critical questions about patient care for individuals with disabilities and the responsiveness of healthcare systems to family advocacy. The OHO report serves as a stark reminder of the importance of effective communication and patient-centered care in hospitals.
