Inquests into the deaths of Anna Panella, Anthony Skeffington and Graham Jessett who died after waiting extended periods of time for an ambulance

A man who died by choking on his own vomit after waiting hours for an ambulance is among three victims whose deaths are being probed in Adelaide inquests.

Bernard "Brian" Skeffington pictured with his nephew (left) James and son (right) Martin.

Three people who died while being ramped – one for up to six hours – have been revealed in an inquest before the Deputy State Coroner.

The inquest, investigating the deaths of Anna Vincenza Panella, 76, Bernard Anthony Skeffington, 89, and Graham Henry Jessett, 64, started on Tuesday where it was revealed they all suffered medical complications after being ramped for extended periods of time.

Opening the inquest into the three deaths, counsel assisting Darren Evans said the inquest would investigate why the patients were left waiting extended in ambulance bays at respective hospitals.

Mr Evans said the inquest will hear how each person was let down by the health system when they most needed it.

“Each turned to the health system at their time of most need, each was made to wait on the doorstep of a hospital, the health concerns of each escalated to a point where they lost their lives,” he said.

“In this inquest, your honour will hear how these unrelated people were affected by the same issue and how they came to lose their lives.

“It is particularly tragic that the failure to provide care, because of ambulance care, happens on the door step of the hospital which remains just out of reach of those told to wait.

“It is particularly tragic that inside the hospital, there are medical staff with all of the skills, all of the knowledge and the best intentions … that sick people just don't get in to see them.”

Mr Evans said Ms Panella died from extensive bilateral pulmonary emboli secondary to left calf deep vain thrombosis on April 28, 2019 after waiting almost an hour in the ambulance.

“The registrar on duty, Dr Sean Jolly, received Ms Panella at 11.30pm in resuscitation, 50 minutes after she had arrived at hospital, about 10 minutes later Ms Panella suffered a respiratory and then cardiac arrest,” he said.

Bernard "Brian" Skeffington, 89, died after waiting five hours for an ambulance.

Mr Evans said Ms Panella had several cardiac arrests before being pronounced dead at 12.39am.

Mr Evans said Mr Skeffington was taken to the Royal Adelaide Hospital on September 25, 2021 after waiting three hours and 42 minutes after the rest call to triple-0.

Mr Evans said a total of three ambulances were dispatched before the one that reached him, with them all being called to jobs considered to be of a higher priority.

“His abdomen was noted to be rigid, he was given medication for his nausea which eased his dry-retching,” he said.

“The ambulance arrived at the RAH at 2.18pm … a note was made on the triage record: ‘the emergency department is currently overcrowded and unsafe, the capacity for clinical assessment and care delivery is compromised as a direct consequence of this and may affect this patient. Hospital executives are aware of this situation.

“He was taken into the emergency department at 4.01pm, one hour and 43 minutes after arriving at hospital.

“At that time he was noted to have a blue, grey appearance, the paramedics advised they were confident Mr Skeffington had aspirated.”

Anna Vincenza Panella died in April 2019 while being ramped. Picture: Supplied

64-year-old Graham Jessett died after being ramped at the Flinders Medical Centre for six hours. Picture: Provided by family

Mr Evans said Mr Skeffington was later taken to comfort care where he died on September 29, 2021 as a result of aspiration pneumonia secondary to small bowel obstruction.

Mr Evans said Mr Jessett, a type 1 diabetic and chronic pulmonary obstructive disease, was “ramped” for five hours.

“When he sat down, he collapsed onto the (hospital bed) and went into cardiac arrest, CPR commenced immediately” he said.

Mr Jessett was pronounced dead at 6pm, after a decision was made to stop resuscitation.

Mr Evans said Professor Anne Marie Kelly, a pre-eminent expert in medicine, will close the inquest.

“She will give her opinion about what happened in each of these cases and also where improvements might be made that have the potential in preventing the loss of life,” he said.

“Professor Kelly’s evidence might assist your honour, as a review of what happened, and what your honour might consider recommending for the future.”

Deputy State Coroner Ian White said an issue throughout the inquest would be determining whether the South Australian Ambulance Service or the respective hospitals were responsible for the patients while they were waiting in an ambulance to be admitted to the emergency department.

“In the terms of the transfer of care, or ramping, situation, as a patient is outside the emergency department doors with an ambulance …, who has the legal responsibility,” he said.

“And that’s a simple question but might be a very complex issue.”

The inquest continues.