Inquest into the death of Angel Blanco-Puerto, Phillip Lindsay, Barry Gaykamangu and Hannu Kononen

Contributing factors

• Failure to identify chest pain as potentially life-threatening in Phillip Lindsay case
• Failure to recognise systolic blood pressure of 70 as indicative of shock in Barry Gaykamangu case
• Failure to activate duty officer protocol when potentially life-threatening conditions should have been identified
• Inadequate persuasion of patient to accept transport in Hannu Kononen case
• Offering alternatives to hospital transport rather than insisting on medical evaluation
• Reliance on patient explanations to exclude cardiac conditions without appropriate testing
• Insufficient recognition of recency of acute MI in Hannu Kononen (one month prior)
• Inadequate training and compliance with Ambulance Not Required policy
• Lack of clinical supervision and on-scene audit mechanisms

Coroner's recommendations

1. The Department of Health and Community Services should give favourable consideration to St John Ambulance's application for funding to create five new clinical support officer (CSO) positions—one shift supervisor per shift on a 24-hour basis—to provide real-time clinical supervision and audit of ambulance officers' clinical judgements
2. The Ambulance Not Required policy should be explicitly amended to clarify that the duty officer must attend in person rather than by telephone or radio communication
3. The updated ANR policy should mandate that ambulance officers explain fully the risks and possible medical complications associated with refusing transport
4. The updated ANR policy should require the attending officer to read the ANR clause to the patient verbatim to confirm understanding
5. St John should conduct hard-nosed educational sessions using real case examples such as these deaths to reinforce the principle that officers should actively persuade patients to accept transport to hospital when there is clinical uncertainty
6. All ambulance officers should receive formal training in the content and application of the ANR policy, with documented evidence of completion
7. Ambulance officers should adopt a conservative approach to chest pain presentations, recognising that pain resolution does not exclude acute coronary syndrome and that all chest pain warrants hospital assessment
8. Systolic blood pressure readings below 90 mmHg should automatically trigger duty officer consultation and senior clinical review
9. Recent history of acute myocardial infarction should heighten clinical suspicion for recurrent cardiac events
10. The ANR policy should explicitly address the culture change needed to avoid ambulance officers assuming the role of gatekeeper to emergency care