Finding into death of Jeannie Anne Patray
Deceased
Jeannie Anne Patray
Demographics
52y, female
Date of death
2008-03-15
Finding date
2009-10-02
Cause of death
Intracerebral haemorrhage secondary to fracture base of skull; rupture of descending thoracic aorta
AI-generated summary
A 52-year-old woman died from intracerebral haemorrhage and aortic rupture after being struck by a vehicle travelling at 100 kph on the Princes Highway near Morwell. She was walking in a traffic lane in darkness without street lighting, attempting to flag down vehicles. A concerned motorist called police (D24) approximately 3-4 minutes before the collision, reporting the dangerous situation. The police operator failed to prioritise this call appropriately, though the coroner found this delay did not contribute to death given the collision's timing. Key clinical lessons relate to the police response system rather than medical management. The finding highlights systemic failures in emergency call prioritisation and the need for clearer protocols when public safety risks are reported.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- pedestrian walking in traffic lane on unlit high-speed road
- poor visibility in darkness
- pedestrian flagging down vehicles in dangerous location
- failure of police operator to appropriately prioritise emergency call reporting dangerous pedestrian behaviour
Coroner's recommendations
- D24 operators be trained generally, and specifically at their local regional level, to be able to identify and prioritise the urgency of 000 calls
- a Sergeant be on duty for each shift of D24 (or be easily accessible to members on duty there) to supervise local D24 operations
- the Standard Operating Procedures be reviewed to clarify and simplify the steps and obligations upon operators at D24 Moe
- Standard Operating Procedures as reviewed at Moe, be taken to a recommended review at State level to standardise the procedures of D24 centres across Victoria
Full text
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