Inquest into the death of Marshall Yantarrnga

Contributing factors

• Failure to transport patient with chest pain to hospital despite observable cardiac scarring
• Ambulance officers did not recognize significance of midline thoracic scar indicating prior cardiac surgery
• Communication difficulties between Aboriginal patient and non-Aboriginal paramedics
• Non-compliance with anticoagulant therapy (Warfarin)
• Lack of recent cardiac follow-up and investigation despite significant cardiac history
• Ambiguity regarding patient refusal versus crew decision not to transport
• Non-compliance with ANR (ambulance not required) policy procedures including lack of written refusal documentation

Coroner's recommendations

1. St John Ambulance should continue implementation of improved ANR (ambulance not required) policy aligned with Dr P.'s recommendations, including mandatory documented refusal forms
2. Paramedics must accept their role is to stabilise and transport patients for hospital assessment, not to act as decision-making gateways to emergency medical assessment
3. Ambulance officers must be trained to recognize clinical significance of chest scars indicating prior cardiac surgery, particularly in patients presenting with chest or unexplained pain
4. Enhanced cross-cultural communication training for ambulance officers to improve interactions with Indigenous patients, including awareness that Aboriginal patients may present as stoic and not explicitly voice concerns
5. All ambulance services should implement systematic audit of ANR cases to ensure compliance with policy and appropriate clinical decision-making