The deputy state coroner has recommended the SA Ambulance Service (SAAS) undertake an urgent review of its resourcing after two patients died waiting for a paramedic more than two years ago.
Ian White spent 22 days investigating whether delays in ambulance response times contributed to the deaths of 54-year-old Craig Malcolm Files in January 2019 and 70-year-old Virginia Anne Weekes in April 2020.
In a statement, SAAS said they are taking the inquest findings seriously and have added staffing since both deaths.
Ms Weekes had to wait 72 minutes for an ambulance after calling SAAS from her Croydon home when she started experiencing abdominal pain and vomiting.
She was given a priority-three 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 Weekes's home, and a second paramedic was not dispatched until 53 minutes after her call.
She waited a further 13 minutes because the paramedics could not find her unit. She was dead when they arrived.
Mr White said two SPRINT ambulances were nearby but under SAAS rules, they were unable to transport a patient and are only staffed by a single paramedic.
"Therefore, there were ambulances available to have gone to Ms Weekes," Mr White found.
"There were some ambulances otherwise unoccupied while Ms Weekes was dying alone, waiting for help to arrive in the form of an emergency ambulance."
Mr White said the SAAS rules should be "adaptable in times of what was described as significant demand for ambulances".
The inquest heard evidence that another call to SAAS for an intoxicated man was given a higher priority than Ms Weekes.
He described that dispatch decision as "troubling" and "poor".
"I find that had she been upgraded to, or initially classified as a priority-two response, there would have been an undeniable prospect of her surviving that night and beyond," Mr White said.
He recommended SAAS review the appropriateness of a priority-three classification for a sick patient with breathing issues and that during periods of increased demand, Emergency Operations Centre clinicians help with dispatch decisions.
A missed opportunity
Mr Files was suffering from multiple medical conditions, including alcoholic liver disease, at the time he had a fall and called for medical help, but had to wait two hours and 10 minutes for a paramedic.
Paramedics attempted to resuscitate the 54-year-old, who had gone into cardiac arrest, but he died at the scene.
Mr White said Mr Files was meant to receive a "call back" after his 30-minute wait time as a priority-three patient had been exceeded.
But he said Mr Files never received one.
The inquest heard that if Mr Files had received a call back, his priority would have been upgraded and he may have received an ambulance much sooner.
"The failure to have a clinician call back the scene once it became apparent that the target response time would be exceeded, deprived Mr Files of the opportunity for a proper consideration by the clinician," Mr White found.
But he said he could not determine whether a priority upgrade would have "necessarily prevented Dr Files's death on that evening".
"I do find that it would have meant at least that medical help reached him much sooner to alleviate his suffering on the floor before he died in his home," Mr White said.
SAAS chief executive Rob Elliott offered his condolences to families of both patients and said the agency have implemented a range of reforms around managing patients and responding to call-outs.
"Our staff do a great job every day and when the outcome for patients is as it was for Ms Weekes and Mr Files, it's heartbreaking and everyone feels it, but no one more than the family involved," Mr Elliott said.
"South Australians expect that when they call triple-0 their call for help will be answered promptly. On both occasions this unfortunately did not occur."
Mr Elliott said while SAAS thoroughly investigated both cases as a matter of urgency, they will also take the inquest findings "seriously".
He said SAAS have strengthened their procedures around the management of patients like Ms Weekes, who was unable to be reached on call back.
"We have also strengthened our process to ensure staff have improved visibility of addresses."
Outside court, Ambulance Employees Association secretary Leah Watkins welcomed the findings, saying the ambulance service has been under "significant pressure for some time" and response times were continually not met.
"Clinicians are having to call back patients for hours and hours on end," she said.
"The most recent one that I've heard of was a priority-three patient that waited up to 20 hours for an ambulance and had multiple call backs over that time.
"That's a risky situation for any patient to be in, to be continually assessed over the phone. There is always a risk of human error or miscommunication."
