Finding into death of Bruce Desmond Andrews

Contributing factors

• major depression with anxiety disorder
• recent relationship breakdown
• acute alcohol intoxication (10 cans of double-strength vodka)
• failure to detect and escalate medication overdose disclosure during welfare check
• inadequate communication systems in dispatch centre (poor audio quality, background noise)
• ambulance demand exceeding supply
• repeated diversions of assigned ambulances to higher priority cases
• significant delay in ambulance response (4 hours 39 minutes from initial call)
• inadequate case prioritisation—remained coded as priority 2 instead of priority 1

Coroner's recommendations

1. Improved communication systems in emergency dispatch centres with better noise dampening and audio equipment quality
2. Enhanced triaging protocols to identify long-waiting cases earlier, with mandatory re-assessment and escalation triggers
3. Implementation of electronic MIMS access at all referral service triage stations
4. Staffing and resource allocation to ensure ambulance supply meets demand during peak periods
5. Clearer documentation and recording of all dispatch decisions and diversions in CAD systems
6. Review of protocols for tricyclic antidepressant overdose management in emergency dispatch
7. Training for emergency services personnel on recognition and escalation of overdose disclosures