‘Absolutely tragic’: Inquiry reveals major failings in ambulance delay death

An Adelaide man who died while pulled over on Anzac Highway waiting for an ambulance had told a triple zero call-taker he had suffered a previous heart attack and was again experiencing classic symptoms – but he was expected to wait two hours for emergency help.

Sep 13, 2022, updated Sep 13, 2022
Photo: Tony Lewis/InDaily

Photo: Tony Lewis/InDaily

Major failings in getting him the urgent care he needed have been laid out in an investigation report released today, prompting a promise from authorities for changes to prevent another such tragedy.

The review, by SA Health chief medical officer Dr Michael Cusack, found that had a paramedic crew been with the 47-year-old father at the time of his cardiac arrest, “he may have been successfully resuscitated at the scene or en-route to an emergency department allowing further treatment for his heart attack to take place on arrival there”.

It comes amid the second worse ambulance ramping figures in SA on record – with patients spending a total of 3763 hours ramped outside hospitals in August.

Releasing the report into the cardiac patient’s death this afternoon, Health Minister Chris Picton said “this is an absolutely tragic situation”.

“Our job is to make sure that we take action to make sure that this does not happen to other families, that we address the problems in the health system that have led to this problem and we’re taking every possible measure to do that,” Picton said.

He also released a second investigation report into the death of a 77-year-old cancer patient who waited more than two-and-a-half hours for an ambulance with head and hip injuries after a fall outside her Andrews Farm home in June.

That review found the care provided to the woman was “far below what would be expected due to the significant delay in an ambulance attending her”.

“Not only did this result in unnecessary pain but risked further harm as the extent of her injuries were at that stage unknown,” the report states.

“The prolonged period on the ground in a cool environment also created a risk for other negative sequalae including pressure injury and is likely to have delayed her subsequent recovery.”

In both cases, the health system was under immense pressure with extreme ambulance ramping and delays.

In the case of the heart attack patient, the man called triple zero on August 8 after experiencing pain in his chest and jaw.

“It was noted in the call that he had a prior history of ischaemic heart disease having experienced a myocardial infarction previously,” the report states.

“Documentation taken during the call also noted that Mr AR was breathing normally but felt clammy.

“Mr AR was documented to be alone in his car and had pulled into a car park adjacent to Anzac Highway in Plympton.”

The report states he first called for help at 5.19pm and was triaged as priority 2, meaning he should have received an ambulance within 16 minutes.

A call-back message was “initiated” 11 minutes later “to advise that an estimated time of arrival (ETA) for an ambulance was 2 hours”.

“The call-back occurred at 17:51 but it was not possible to establish contact with Mr AR and a voicemail message was left,” the report states.

“A second call to SAAS was received at 17:54 from a bystander at the scene who had found Mr AR to be collapsed and unresponsive in his vehicle.”

His status was upgraded to Priority One, and an ambulance arrived shortly after – 41 minutes after his initial call.

He was unable to be resuscitated and died.

The report notes that the ambulance service was extremely busy on that day, with 902 triple zero calls answered between 7am and 6am the following morning.

“The information that Mr AR provided in his Triple zero call indicated that he was at high risk as he described typical symptoms of chest pain radiating to his jaw with a background history of a previous heart attack,” the report states.

“Additionally, he was alone without someone available nearby to monitor his condition while the ambulance was awaited and to update SAAS if required.

“Cardiac monitoring with immediate access to resuscitation is crucial soon after the
 onset of a heart attack as serious arrhythmias are commonplace and the chance of a 
successful outcome in the event of a cardiac arrest diminishes with delay.”

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The report makes a number of recommendations including a review of how patients identified as likely to be experiencing a heart attack are prioritised “to ensure they have effective resuscitation available to them as soon as possible”.

“It is recommended that these patients should be prioritised to receive the first available ambulance response,” it says.

It also calls for clinical support to assist in dispatch decisions when the ambulance service is under sustained pressure and for SAAS to consider measures to improve ambulance response capacity during periods of high predicted demand until additional resources are brought on line.

“There is an urgent need to improve whole of hospital and system flows to reduce transfer of care delays and the resultant risk to patients in the community waiting for an ambulance,” it says.

Picton said the government would adopt all recommendations and he had today written to all local health networks advising them of the need for change.

He said the government, health representatives, fire services and unions were continuing to meet to discuss how the Metropolitan Fire Service could be used to help patients in emergencies on days of extreme demand.

“Within the next few weeks… we should be in a position where we have at least got some initial agreements between how the MFS and SAAS will be working better in terms of responding to some of these cases,” he said.

“But… the majority of the issue has to be dealt with in the health system.

“There will be times though where an MFS response to some of these cases would be very beneficial and could help to respond to some of the urgent cardiac cases that we see in the community.

Picton also today announced a new partnership to free up more beds and improve flow in the hospital system.

Griffith Rehabilitation Hospital at Hove will provide 30 extra beds to Flinders Medical Centre patients who no longer need acute care but require additional support before transitioning back home.

Picton said the beds would be available to NDIS, aged care and sub-acute rehabilitation patients through a referral.

The number of hours ambulances spent ramped outside hospitals in August was the second worst on record, with patients stuck for a total of 3763 hours, just below a record set in June, when 3838 hours were lost.

“We are amazed and disappointed about these ramping statistics that have come out today,” Opposition spokesperson Michelle Lensink said.

“We’ve got a government which has been elected with a promise to fix ramping and we’ve got the worst statistics ever – we are so far behind under this Labor Government from fixing the hospital system.”

Picton hit back, saying the Government had “inherited” a health system “that does not have enough beds, that does not have the capacity that we need, that does not have enough ambulances, that does not have enough inpatient care”.

“And we have opened up every single possible bed that we have and we’ve brought on every other possible bed that we can from the private system as well,” he said.

“We are using ever lever possible to address this situation.”

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