Deceased
John Douglas Kennedy
Demographics
65y, male
Date of death
2020-04-16
Finding date
2025-10-20
Cause of death
Ischaemic heart disease on a background of hypertension
AI-generated summary
John Kennedy, 65, died from ischaemic heart disease with hypertension on 16 April 2020 after a 24-minute delay in ambulance dispatch. He called triple zero at 00:19 with severe chest pain and difficulty breathing (Priority 2, chest pain determinant 10D02). The dispatcher verbally assigned the nearest crew (Barker 181, 6 minutes away) but waited 8+ minutes without confirmation. Meanwhile, Barker crew's paramedic phoned requesting reassignment to a lower-priority hospital transfer, which the dispatcher granted. Stirling crew (14+ minutes away) were then dispatched instead. Kennedy arrested at ~00:44; paramedics arrived at 00:43 but defibrillation occurred after the critical 5-minute window when survival chances are highest. Expert cardiologist testimony established that with prompt dispatch and early defibrillation within 5 minutes of arrest, Kennedy had reasonable chance of survival. Key failures: dispatcher's vague communication with crew, paramedic's interference with dispatch process, reassuring caller that ambulance was 'on way' before dispatch occurred, and failure to immediately task available crew. The death certificate was signed without coronial report despite meeting 'unusual' criteria, delaying investigation by nearly a year.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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