Coronial
NThome

Inquest into the death of Stephen Power

Deceased

Stephen John Power

Demographics

35y, male

Date of death

2003-09-05

Finding date

2004-08-05

Cause of death

left lower lobe pneumonia

AI-generated summary

Stephen John Power died of left lower lobe pneumonia on 5 September 2003 after two failed emergency calls requesting ambulance assistance. On Thursday 4 September, dispatcher Coralie Holland failed to send an ambulance despite the caller reporting laboured breathing and need for assistance with toileting. On Friday 5 September, dispatcher Karen Joyner improperly refused to send an ambulance, making inappropriate questions about payment and being dismissive of the caller's legitimate concerns. The coroner found both dispatches should have resulted in ambulance dispatch. A senior St John's officer agreed an ambulance should have been sent. The coroner concluded that had an ambulance been sent Thursday, appropriate treatment may have saved the deceased's life. St John's Ambulance subsequently implemented systemic improvements including revised dispatch policies, cross-cultural training, and call recording procedures.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineparamedicinegeneral practicepathology

Error types

communicationsystemdelay

Drugs involved

flucloxacillinbactoban ointment

Clinical conditions

pneumonialower respiratory tract infectionsevere dyspnoea

Contributing factors

  • failure to dispatch ambulance on first call (4 September 2003)
  • failure to dispatch ambulance on second call (5 September 2003)
  • dispatcher dismissal of caller concerns
  • inappropriate questions about payment for ambulance service
  • inadequate assessment of clinical severity by dispatchers
  • lack of cross-cultural training for emergency dispatchers
  • dispatcher fatigue and workload pressure
  • lack of structured clinical assessment protocol at time of first call
  • patient's initial reluctance to seek medical care
  • delayed antibiotic therapy

Coroner's recommendations

  1. Implementation of policy that EMDs do not fail to dispatch ambulances except in clearest circumstances
  2. Counselling of staff involved in failed dispatch calls
  3. Workshop participation for all communications officers including cross-cultural training
  4. Update of procedures manual with focus on clinical decision-making
  5. Installation of internal call recording apparatus to allow performance monitoring and review
  6. Ongoing cross-cultural training especially concentrating on Aboriginal language and barriers to accessing services
  7. Ongoing communication training for dispatchers
  8. Regular review and updating of procedures manuals
Full text
Official source Archived copy

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Source and disclaimer

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