Deceased
Lorraine Mary Bartolome
Demographics
73y, female
Coroner
Coroner Jacqui Hawkins
Date of death
2015-06-08
Finding date
2016-02-17
Cause of death
Exsanguination from ruptured varicose vein right lower leg
AI-generated summary
A 73-year-old woman died from exsanguination following rupture of a varicose vein on her right lower leg while on anticoagulation therapy (dabigatran) for atrial fibrillation. She called emergency services at 1:22 am on 8 June 2015. The ESTA call-taker incorrectly downgraded the priority from code 1 to code 3 at 1:25 am, based on the patient's unclear statement about bleeding control. This caused diversion of the initially dispatched ambulance. Ambulance Victoria's Duty Manager failed to respond to four subsequent dispatcher requests for dispatch solutions between 1:27 am and 2:04 am, missing opportunities to refer the case to the referral service for welfare assessment and potential case reprioritisation. An ambulance was not dispatched until 3:03 am. The coroner found the patient likely could not have been saved despite earlier intervention, but identified a preventable system failure in emergency response coordination.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
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