Finding into death of Kylie Jane Cay

Contributing factors

• downgrading of ambulance response priority from Code 1 to Code 3 without adequate investigation
• cancellation of ambulance attendance based on reassurance from recent hospital discharge
• failure to recognise vulnerability and severity of presentation
• lack of family violence awareness in emergency dispatch and triage protocols
• poor listening and empathetic approach by triage operator
• failure to arrange transport for patient with no means of accessing hospital
• delayed rupture of spleen not visible on initial CT imaging
• failure to explore mechanism of injury comprehensively
• incomplete and inaccurate information provided to clinicians about injury timeline

Coroner's recommendations

1. Ambulance Victoria to ensure clinicians and referral service triage practitioners can access all information taken by ESTA call operators, including ProQA codes and descriptions in the Computer Aided Dispatch system
2. Ambulance Victoria to conduct internal review to ensure all staff have received training and education about injuries and harm caused by family violence as outlined in Pro Ops 273 (approved 29 July 2020)
3. Ambulance Victoria to use this finding and transcript of Ms Cay's call with referral service triage practitioner for staff education and training regarding family violence and active empathetic listening
4. Ambulance Victoria to audit policies and work instructions to ensure alignment between policies and internal compliance, identifying and addressing discrepancies
5. Corrections Victoria to introduce electronic case management system to enhance monitoring of offender compliance with Community Corrections Orders, including capacity to create schedules with milestones and automated supervisory oversight
6. Corrections Victoria to implement training for all staff state-wide involved in preparation of Judicial Monitoring reports regarding their composition and contents to improve quality and accuracy