Home Health Inquest recommends SA Ambulance Services review staff after two people died waiting...

Inquest recommends SA Ambulance Services review staff after two people died waiting for ambulances


The Deputy State Coroner has recommended that SA Ambulance Service (SAAS) urgently review its resources after two patients died while waiting for paramedics more than two years ago.

Ian White spent 22 days trying to find out if it was delays in EMS response times contributed to death Craig Malcolm Files, 54, in January 2019 and Virginia Ann Weeks, 70, in April 2020.

Ms Weeks had to wait 72 minutes for an ambulance after SAAS was called from her home in Croydon when she started having stomach pains and vomiting.

She was given a third priority response, which meant she should have received help within 30 minutes, but an ambulance was not dispatched for 42 minutes.

That ambulance was diverted to another job when it was 2km from Ms Weeks’ home and a second paramedic was only dispatched 53 minutes after her call.

She waited another 13 minutes because paramedics couldn’t find her machine. She was dead when they arrived.

Mr White said two SPRINT ambulances were nearby but in accordance with SAAS regulations they were unable to transport the patient and only had one paramedic on staff.

“So there were ambulances available to go to Ms Weeks,” Mr White revealed.

“Several ambulances were unoccupied while Ms Weeks lay dying alone, waiting for help in the form of an ambulance to arrive.”

Mr White said the SAAS rules should be “suitable at a time of what has been described as significant demand for ambulances”.

Both patients died before reaching the hospital.(ABC News: Che Chorley)

The inquest heard evidence that another call to SAAS for an intoxicated person was given higher priority than Ms Weeks.

He called the sending decision “disturbing” and “bad”.

“I believe that if she had been upgraded to or initially classified as a priority two response, she would have had an indisputable chance of surviving that night and beyond,” Mr White said.

It recommended that SAAS review the appropriateness of a third-priority classification for an ill patient with respiratory problems and that, during periods of increased demand, ED clinicians assist in the referral decision.

A missed opportunity

Mr Files was suffering from a range of medical conditions, including alcoholic liver disease, when he collapsed and called for paramedics but had to wait two hours and 10 minutes for paramedics.

Medics tried to resuscitate a 54-year-old man who suffered a cardiac arrest, but he died on the spot.

Mr White said Mr Files should have received a “callback” after his 30-minute waiting time as a priority three patient was exceeded.

But he said Mr Files never received it.

The inquest heard that if Mr Files had been called back, his priority would have been raised and he may have received an ambulance much sooner.

“The fact that the clinician did not call the scene once it became apparent that the target response time would be exceeded deprived Mr. Files of the opportunity for a proper review by the clinician,” Mr. White believed.

But he said he could not determine whether a priority upgrade would necessarily have “prevented Dr. Files’ death that evening.”

“I believe it would have meant, at the very least, that medical help would have reached him much earlier to relieve his suffering on the floor before he died in his home,” Mr White said.

A woman in a beige jacket stands near a building.
Leah Watkins says patients are waiting too long for an ambulance.(ABC News: Megan Dillon)

Outside court, Ambulance Service Association secretary Leah Watkins welcomed the findings, saying the ambulance service had been under “significant pressure for some time” and response times were consistently failing.

“Clinicians have to call patients back for hours on end,” she said.

“The last one I heard about was a Level 3 patient who waited up to 8pm for an ambulance and had several callbacks during that time.

“It’s a risky situation for any patient to be constantly evaluated over the phone. There’s always the risk of human error or miscommunication.”


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