Review completed into patient death following ambulance delay
A high-level review into the circumstances surrounding the tragic death of a patient following a prolonged wait for an ambulance last December has been completed, with full findings and recommendations released today.
The SA Ambulance Service has committed to implementing all seven recommendations to improve the system.
The review was carried out by SA Chief Medical Officer Dr Michael Cusack, SAAS Chief Medical Adviser Dr Amy Keir and SAAS Operations Manager Clinical Improvement Cathy Wright.
The patient’s family has asked SA Ambulance Service to request that media do not report the patient’s name or publish or broadcast any images of the patient.
The review found ambulance ramping was a major contributor to the delay in reaching the patient, there were delays in the call-back process due to a high Triple Zero call volume and that the risk profile for a vulnerable patient in this case was “underappreciated”.
This review did not investigate cause of death which is ultimately a matter for the Coroner.
The review has made 7 recommendations – all of which will be adopted by SAAS – including:
Better identifying cases of greatest risk and implementing procedural guidance to help prioritise call-backs during periods of high demand, particularly for vulnerable patients
Implementing changes to improve the internal escalation process of call-backs where clinical concerns are identified and there is no ambulance to send
Refining current operational procedures, reporting and dispatch to optimise all components of internal ambulance capacity, especially to delayed cases
Undertaking a review to better assess response to care of vulnerable patients who rely on a second party for communication
Refining call-back procedures to ensure confirmation that the second party caller is with the patient at the time of the call
SAAS will include learnings from this review whilst undertaking a new pilot project using video technology for clinicians in its Emergency Operations Centre, set to improve the way lower acuity patients are clinically assessed and reviewed.
A clinical improvement working group reporting to SAAS Chief Executive Officer Rob Elliott will be commissioned to oversee the implementation of the recommendations, and the SAAS Clinical Governance Committee, which has external representatives, will monitor progress.
Full findings and recommendations can be found here.
Quotes
Attributable Chris Picton
This death was a tragedy that shocked the entire state. We acknowledge the immense pain caused to the family and we extend our deepest condolences.
We are committed to doing absolutely everything we can to improve ambulance response times and reduce ramping to help prevent such future tragedies.
Our ambos work tirelessly for the South Australian community, often in very difficult circumstances, and I thank the reviewers for their recommendations that will help ensure our patients get the most appropriate care when calling an ambulance.
The findings and recommendations are accepted in full and SAAS will immediately get to work on implementing them to improve the system.
Attributable SAAS Chief Executive Officer Rob Elliott
Any death that occurs in SAAS care is a tragedy and we are dedicated to making any improvements that we can make. I am incredibly grateful for the review team for their diligent work in identifying these recommendations for a safer ambulance service.
While this review focuses internally on SAAS, and the improvements we can make ourselves, the need to ensure ambulances are available to the community is paramount and must not be overlooked.
These recommendations will improve the efficiency and effectiveness of our internal safety nets for delayed responses when ambulances are not available, and I am committed to supporting these changes to improve patient safety and help prevent future tragedies.