Finding into death of Lorraine Mary Bartolome
Deceased
Lorraine Mary Bartolome
Demographics
73y, female
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.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Anticoagulation therapy (dabigatran) for atrial fibrillation increasing bleeding risk
- Incorrect call prioritization by ESTA call-taker at 1:25 am (code 1 downgraded to code 3)
- Ambulance diversion following incorrect downgrade
- Failure of Ambulance Victoria Duty Manager to respond to dispatcher requests for dispatch solution
- Failure to activate welfare callback protocol and case reprioritisation
- High ambulance demand with restricted fleet availability due to dispatch warnings
- Communication breakdown between Duty Manager and Communications Support Paramedic
- Delayed ambulance dispatch (1 hour 41 minutes from initial call)
Coroner's recommendations
- Ambulance Victoria to update operational work instruction WIN/OPS/304 (Management of Response Delay) to enable referral service call-takers to carry out welfare callbacks for cases in pending box without waiting for Duty Manager prompt
- Ambulance Victoria to stagger shift start times and alter shift durations to combat decreasing resource availability due to dispatch warnings
- Development and implementation of escalation process between ESTA and Ambulance Victoria whereby dispatcher can refer matter to ESTA team leader who will verbally notify Ambulance Victoria Duty Manager when immediate dispatch solution cannot be found
- Inspector-General for Emergency Management to review ESTA's investigation into the incident and monitor implementation of recommended actions
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