George and Theodora Taousanis, whose father and husband died of stroke in August. Credit:Robert Peet Fairfax Media has confirmed the details of two other cases, and doctors claim 250 to 400 patients have died or been left incapacitated under similar circumstances. Endovascular clot retrieval is a cutting-edge procedure that involves manually extracting the blood clot that caused the stroke through a tube fed into a major artery and is suitable for up to 25 per cent of patients who suffered an ischaemic stroke. The first line treatment for most stroke patients is clot-busting medication and this remains available 24 hours. But hospitals have not been resourced to provide endovascular clot retrieval around the clock since trials proved its superiority over standard drug treatment and it moved into mainstream medical practice in late 2014.

Theodora Taousanis sits by her husband, Nick Taousanis, in Prince of Wales Hospital after he had a stroke. Credit:George Taousanis INR specialist Jason Wenderoth said doctors were aware of two deaths in the last few months and other cases where people had completed their strokes and ended up in a nursing home because the theatres could not be opened after hours. Doctors reported each of them to health administrators as "SAC-1" events – the most serious category of clinical incident. But in each case they were downgraded by the local health administration, which meant they were not forwarded to the ministry. "There are plenty of doctors, but they won't fund doctors, nurses and technicians to work after hours," Dr Wenderoth said. "[Endovascular clot retrieval] is the most significant breakthrough in my career in medicine. It is 10 to 15 times as effective in getting patients back to normal as stenting for coronary artery disease."

Anticipated demand for the procedure has created an industrial stand-off between specialists in interventional neuroradiology [INR] and the state government. The handful of doctors qualified to perform the procedure in NSW claim they are inadequately compensated for after-hours work and local health chiefs have launched an overseas recruitment drive for new INR clinicians to shore up their negotiating position. INR clinicians say their numbers are sufficient, but the department has not provided funding for theatres, ICU beds, nurses, radiographers and anaesthetists for endovascular clot retrieval. TOO LATE FOR PROCEDURE Mr Taousanis, 81, was admitted to Wollongong Hospital on August 13 after he was felled by a huge stroke at his home in Shell Cove.

He was identified as a good candidate for endovascular clot retrieval and an ambulance was ordered to transfer him to Prince of Wales Hospital, but it was 90 minutes late and Mr Taousanis did not arrive until close to 9pm. The INR specialist was waiting for Mr Taousanis, but told the family that the operation could not be performed due to hospital policy, Mr Taousanis' son George said. "I said, 'If it's a cost issue let me know and I will pay'," George Taousanis said. "The doctors then proceeded to tell me that there were no more procedures available for my father and the blood clot would continue to block oxygen and blood to his brain causing considerable and irreversible damage to his brain, which in turn would more than likely cause him to die." Two days later, the hospital administrators called him to a meeting where they explained that the doctor been ready to perform the operation but could not because the team had finished their shift at 8pm.

"I was really angry because they were talking about my father's life," George Taousanis said. "I was appalled that the team did not stay back to assist with the operation." Doctors reported the incident as a "SAC-1", but this was downgraded by hospital administrators to a SAC-2. South Eastern Sydney Local Health District medical director James Mackie told Fairfax Media the operation did not go ahead because it was more than six hours after the stroke and outside clinical guidelines for endovascular clot retrieval to be performed. But he said it could have been better handled.

"Although it was unlikely the patient would have gained therapeutic benefit from the procedure, the matter should have been escalated to the Chief Executive for consideration of the procedure taking place outside the usual hours of service," Dr Mackie said. The incident was reclassified as a SAC-2 after an independent review, he said. NSW Health said the unavailability of a procedure at a particular hospital would not ordinarily constitute a SAC-1 incident. MORE PATIENTS But Mr Taousanis is not the only patient who missed out on treatment after hours.

A 64-year-old man admitted to Nepean Hospital in November last year died after he arrived out of hours and was not transferred to Westmead where an endovascular clot retrieval could have been performed. INR specialist Brendan Steinfort subsequently complained to the Nepean health chief in an email obtained by Fairfax Media that it appeared an endovascular clot retrieval had been attempted by an untrained practitioner. "As a result not only was the stroke not treated, but the stroke was made a good deal worse," Dr Steinfort's email said. "The patient now looks like they will need the bone removed from their skull to cope with the swelling, and may well die regardless." Nepean Blue Mountains Local Health District said in a statement that a panel of experts had investigated the incident and found no evidence that a doctor had performed outside their scope of practice.

It found the care had been appropriate and in accordance with guidelines. A third patient, 89-year-old Edward Grubel, died in September after he presented out of hours for a stroke that doctors said was suitable for endovascular clot retrieval. Mr Grubel's granddaughter, Brittney Grubel, said he was transferred from St George Hospital to Liverpool Hospital because the closer facility, Prince of Wales, did not accept patients after 7pm, and by the time he arrived it was too late. "We will never know whether [an endovascular clot retrieval] would have been effective," said Ms Grubel, who works as a radiographer at Prince of Wales. "It's frustrating when there are good services and great doctors and we're unable to provide this at certain times of the day."

POLITICAL BATTLEGROUND The advent of endovascular clot retrieval as a stroke treatment has created a stand-off between the nine INR specialists qualified to perform the procedure in NSW and the state government. INR specialists approached the NSW government in 2012 with concerns they were working long hours for inadequate remuneration for their after-hours work, which on an award rate of $198 per hour was reduced to $80 an hour after parking, tolls, taxes and having to cancel their surgical lists the day after being called out. NSW Health originally invited them to submit a tender for a statewide neurointervention service, but negotiations broke down over the price, with seven clinicians who formed a company to bid for the contract seeking more than double the $10 million that the local health chiefs were collectively willing to offer. The parties then entered "direct negotiations" with the local health chiefs, but these also petered out when the parties differed over the scope of the solution. The INR clinicians wanted to lock into place a broad service agreement where after-hours activity was concentrated at two hospitals, while the department's proposal focused on an after-hours metropolitan-wide roster and some extra funding for the clinicians.

MEETING THE DEMAND FOR AFTER HOURS PROCEDURES INR clinicians estimate it would cost $30 million for the NSW government to set up a system similar to the one that exists in Victoria where after-hours cases are transferred to one of two hospitals designated to perform the procedure overnight. This would include $4 million to $6 million for theatre upgrades, staff and imagery at each of the six adult hospitals in NSW that currently conduct the procedure, with 1 to 2 per cent used to pay doctors for after hours. NSW Health said in a statement there were protocols for after-hours treatment and health districts arranged with other sites to transfer patients and ensure they got the right treatment. NSW Health deputy secretary of strategy Nigel Lyons said the department was not aware of any cases in which patients had missed out on care through a lack of support staff, and if they occurred they should be escalated to the chief executive immediately.

The hospitals had an after-hours network and health districts would boost their capability to do the procedure at night as demand increased under the activity-based funding model, he said. "The plan was, when there were times that there was a hospital that didn't have these services available, there was a hospital that did have that cover," Dr Lyons said. "We have data that these procedures are being done [after-hours] at a number of hospitals across the district." A draft planning report on neurointervention services recommends the recruitment of 12 to 18 INR specialists over the next 15 years, which would provide for each of them to perform 100 procedures over three years. But INR clinicians say that if there are too many doctors in the field they will not each be able to perform the minimum 33 procedures each year that is required to maintain their skills in Australia.

Most international societies recommend 80 cases a year. "The workforce should be grown in response to demand, not just to fill a roster or break an industrial deadlock," Dr Wenderoth said. "The money used to pay for these people could be far better spent right now in getting staff and equipment to open 24 hours, even if they don't pay the doctors one extra cent."