Coroner's Finding: Gray, Alan Maurice
Deceased
Alan Maurice Gray
Demographics
77y, male
Date of death
2020-09-19
Finding date
2022-03-01
Cause of death
traumatic closed head injury due to a fall from standing
AI-generated summary
Alan Maurice Gray, 77, suffered a fall at a service station on 16 September 2020, hitting his head. He called for an ambulance at 7:54pm but paramedics did not arrive until 12:09am (4 hours 15 minutes delay). CT imaging revealed extensive intracranial haemorrhage and he died on 19 September. The ambulance delay was caused by triage error (incorrect priority coding), failure to upgrade priority after failed call-back, and system factors including insufficient crews and patient off-load delays. The coroner found that while the delay denied Mr Gray any chance of recovery, expert medical opinion indicated the outcome would likely have been fatal regardless. Ambulance Tasmania subsequently implemented corrective measures including staff education and new call-back protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- triage error in Medical Priority Dispatch System (incorrect priority coding)
- failure to upgrade priority after failed call-back attempt
- patient off-load delay at Royal Hobart Hospital
- insufficient ambulance crews
- high caseload in Southern Region
- extensive intracranial haemorrhage
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