Coroner's Finding: GEORGE Patricia Nina
Deceased
Patricia Nina George
Demographics
81y, female
Date of death
2002-07-27
Finding date
2006-05-22
Cause of death
aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphysema) and congestive cardiac failure
AI-generated summary
Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay occurred when her initial request (5:45 am) was cancelled due to lack of staff to accompany her as a detained patient, then rebooked at 6:20 am with ambiguous priority designation. The ambulance dispatch was further delayed by a shift changeover policy. She was not transported until 7:41 am and died at Royal Adelaide Hospital by 11:20 am. Key failures included: inadequate communication between nursing and ambulance service about clinical urgency, lack of medical input into priority designation, lost/destroyed ambulance request records, and critically deficient investigation (most witnesses interviewed 3+ years post-event, investigation took three years). The coroner found the investigation hampered by systemic delays in Adelaide CIB prioritisation of deaths in custody inquiries, preventing timely identification and rectification of procedural failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- failure to recognise clinical urgency in ambulance priority designation
- loss of medical input into ambulance priority classification
- staff shortage preventing immediate escort arrangement for detained patient
- unclear communication between ward staff and admissions clerk regarding priority
- ambulance service shift changeover policy delaying dispatch of priority three calls
- ambiguous language ('priority two or something') creating operator interpretation ambiguity
- cancellation of initial ambulance booking
- delay of 1 hour 22 minutes from rebooking to ambulance dispatch
- inadequate clinical handover procedures to admissions/switchboard staff
Coroner's recommendations
- Commissioner of Police review the operations of Adelaide CIB to determine why Senior Constable Della Sala's investigation took three years to complete
- Review to be conducted by an officer of sufficient senior rank to ensure thorough outcome
- Commissioner of Police take steps to ensure investigations into deaths in custody are conducted in a timely fashion and completed within twelve months of the date of death
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