Coroner finds Ambulance Tasmania procedures lacking following elderly woman’s death

A coroner has found Ambulance Tasmania’s procedures and training were lacking after the death of an elderly woman who had declined a trip to hospital. FULL CORONER’S REPORT >>

• Coroner finds RHH ED failures connected to man’s self-harm death
• Coroner slams hospital over fatal overdose of mesothelioma patient

A CORONER has pointed to a deficiency in Ambulance Tasmania’s training and procedures after a paramedic gave an elderly woman the option of “doing nothing” following a fall, only to die a few days later.

Valerie Joy Bowerman, 80, had seemed fine after slipping and falling on concrete outside her Derwent Valley home while collecting firewood in September 2017.

The grandmother had a mark on the top of her cheek but was alert and talkative, declining a trip to hospital when Ambulance Tasmania paramedics arrived.

But over the coming hours, her condition deteriorated to the point that a trip to hospital was unavoidable.

However, by then it was too late to consider any treatment options.

A few days later, Mrs Bowerman – who was on the anticoagulant Warfarin – died from severe bleeding to the brain.

In February this year, a two-day inquest was held to examine the circumstances of her death and the adequacy of Ambulance Tasmania training.

In her findings released on Wednesday, Coroner Olivia McTaggart said she had examined whether paramedics should have or could lawfully have transported Mrs Bowerman to hospital when they first attended her home, despite the Magra resident not showing signs of a serious head injury at that time.

She said the two paramedics – an AT staff member and a volunteer – were likely unaware that Mrs Bowerman probably hit her head on concrete or that she had spent close to an hour on the ground.

During the inquest, the paramedics said Mrs Bowerman had become “firm” and “very feisty” at the suggestion she be transported to hospital, asserting she wished to stay home and wait for her daughter.

But two of Mrs Bowerman’s children argued their mother would have been convinced if she had been given advice about the risk of death.

Ms McTaggart did not make a finding on whether earlier treatment could have prevented her death, noting there was a “high chance” the outcome would have been no different.

However, she said the delay meant Mrs Bowerman “lost a possible opportunity for successful treatment”.

She said the AT paramedic gave Mrs Bowerman the option of “doing nothing”, which showed he had not appreciated the risks involved.

However, she said the issue could not be viewed as wholly or substantially a personal failing on the paramedic’s behalf.

“The issue can largely be attributed to inadequacies by Ambulance Tasmania in paramedic training and implementation of guidelines and procedures,” she said.

She said the paramedic had not received formal training into, and wasn’t aware of, clinical practice guidelines for the mandatory transport of elderly patients on Warfarin with head injuries.

She reinforced recommendations for AT to develop formal procedures addressing the difficulties for patients either not transported to hospital, or who have refused transportation or treatment.

Follow @ambervwilson