Finding into death of Robert Norman Spencer
Deceased
Robert Norman Spencer
Demographics
59y, male
Date of death
2022-02-18
Finding date
2024-04-23
Cause of death
ischaemic heart disease in the setting of chronic ethanol use
AI-generated summary
Robert Spencer, 59, called 000 at 4:27 am reporting weakness and inability to mobilise following a fall. He was triaged as Code 3 (non-urgent) and underwent secondary triage call-back attempts without success. An ambulance was not dispatched until 7:08 am, arriving at 7:38 am, by which time Robert was found in cardiac arrest and deceased. The autopsy confirmed ischaemic heart disease with chronic ethanol use as the cause. The 3-hour delay was attributed to staff shortages and decreased fleet availability rather than clinical factors. The pathologist could not determine whether earlier intervention would have changed the outcome. The coroner found the delay regrettable but due to systemic issues in ambulance operations, with Ambulance Victoria undertaking multiagency review to address fleet availability problems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- chronic heavy alcohol consumption (1-2 bottles wine daily)
- heavy smoking
- coronary artery atherosclerosis
- myocardial fibrosis
- emphysema
- hepatic steatosis
- alcohol withdrawal complications
- ambulance fleet availability shortage
- hospital ramping delays
Coroner's recommendations
- Ambulance Victoria to continue multiagency review with Department of Health and Safer Care Victoria to address fleet availability and ambulance delays
- Investigation into feasibility of upgrading priority code for patients unable to be reached via Secondary Triage call-back was deemed inadvisable due to high frequency of call failures (1,634 cases monthly) without clear clinical significance and risk of worsening response times to other priority calls
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