Coroner slams SA Ambulance Service response to death of woman, 70, and man, 54

The coroner has blasted the SA Ambulance Service after a 70-year woman died in pain while ambulances sat idle. When an ambulance was eventually sent, it was diverted to a drunk.

A woman in pain, vomiting and with breathing difficulties who called triple-0 for help died alone in her home while two unoccupied ambulances sat idle and another was on a break nearby.

An ambulance was eventually dispatched 42 minutes after Virginia Anne Weekes, 70, called for help and was incorrectly listed as a priority 3 patient, with a response target of 30 minutes.

However, when it was just 2.5km from her Croydon home it was diverted to a incoherent call from a drunk who it turned out did not need transport to hospital.

When a crew finally arrived 72 minutes after she rang for help, they found her dead.

Deputy State Coroner Ian Lansell White conducted a joint inquest into the deaths of Ms Weekes and also Craig Malcolm Files 54, who died on the floor of his Norwood unit in January 30, 2019, after waiting two hours and 10 minutes for an ambulance amid ramping.

He made multiple recommendations to the SA Ambulance Service including “an urgent review of ambulance resourcing within the metropolitan area to identify current and future requirements that will ensure patient safety.”

Virginia Weekes died after waiting for an ambulance in Adelaide. Picture: Supplied

Mr White found unanswered questions in the death of Ms Weekes, a successful professional violinist, on April 4, 2020 caused by acute aspiration complicating bowel obstruction – she had undergone emergency surgery for a bowel obstruction three months earlier.

In a sad touch of irony Mr White, referring to the recording of the triple 0 call, noted he “was amazed by the calm and dignified manner in which she conducted herself so close to her death”.

“Looking objectively, her calm manner and precise use of language, understated the seriousness of her condition,” he wrote in his findings. “Her composure almost of itself falsely signified a lack of urgency as well.”

On the day before her death Ms Weekes had a telehealth consultation with her GP Dr Yehudi Yeo where her symptoms were put down to gastroenteritis.

However, after repeated vomiting which had gone on for four days she texted her sister Diana at 6.44pm the next day, rang locum service MedVisit Home Doctors Service at 6.45pm but was unable to get a doctor, and rang triple 0 at 6.51pm which ended with the promise from the operator to Ms Weekes to “see you soon.”

The SA Ambulance Service is under the assistant coroner’s scrutiny after the tragic deaths of a man and a woman. Picture: NCA NewsWire / Dean Martin

However no ambulance was sent and a call-back at 7.41pm went unanswered and Ms Weekes was removed from the call-back queue.

At 7.26pm her sister Diana, unable to contact Ms Weekes by phone, rang triple 0 on her behalf and at 7.36pm an ambulance was finally sent but Mr White noted: “There has been no satisfactory explanation as to why it took 42 minutes for her call to be subject of a dispatch.”

Mr White found there were two full paramedic team ambulances available at the time as well as a single paramedic SPRINT ambulance – but it was on a crib – meaning meal – break.

“There were some ambulances otherwise unoccupied while Ms Weekes was dying alone waiting for help to arrive in the form of an emergency ambulance,” he found.

“Being classified a Priority 3 response is that unlike Priority 1 and 2, crib

breaks could not be broken and crews close to finishing their shift could not be sent.”

Mr White’s finding notes when an ambulance was finally sent, it was diverted when just 2.5km away.

“An intoxicated person who could not explain properly why he was calling, was given a higher priority than a very sick 70-year-old woman who, despite the immense suffering that she must have been enduring, calmly and carefully described her symptoms,” he found.

“It leaves the conclusion that quite simply it is a significant problem if an intoxicated man who cannot explain his symptoms, interfered with the response of an ambulance crew to a 70-year-old woman with abdominal pain, vomiting with abnormal breathing, living alone and who has failed to answer a return call.”

When a crew finally arrived at 8.06pm, 72 minutes after Ms Weekes’ call for help, they found her dead. The officers spent 13 minutes trying to find the right unit, a situation Mr White said “must not be repeated in the future”.

Mr White concluded: “I cannot exclude that her death may have been preventable had an ambulance arrived earlier. I also cannot exclude that if her life could not be saved, she may have at least avoided dying alone. The exceptionally long wait for a response resulted in her coping alone with her own death.”

He similarly found of Mr Files’ death after his partner Ms Petersen rang triple 0 after he collapsed in pain: “I cannot determine whether a potential upgrade would have necessarily prevented Mr Files’ death on this 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.”