Finding into death of Christina Lackmann

Contributing factors

• Ambulance ramping at major hospitals reducing fleet availability
• Non-acute triage coding of 000 call despite patient unable to move
• Inability to provide warm transfer to secondary triage practitioner
• Absence of welfare check protocol when patient unresponsive to callbacks
• High demand on emergency services on evening of call
• Lack of information about drug ingestion in initial triage assessment
• Delayed ambulance dispatch due to resource constraints

Coroner's recommendations

1. Department of Health to signal significant patient safety risks associated with prolonged transfer of patients from Ambulance Victoria to emergency departments and increase visibility and accountability regarding transfer time KPIs
2. Health system review commissioned by Department of Health to identify barriers to effective patient flow through EDs and impact on hospital transfer times and ambulance availability
3. Government funded package to address changing demand across ambulance services, emergency departments and hospitals
4. Ambulance Victoria and ESTA improve provision of information to 000 callers at conclusion of call
5. Ambulance Victoria identify and implement technological support for clinicians to monitor and manage cases pending dispatch
6. Ambulance Victoria investigate capacity for dispatch/welfare checks with Emergency Response partners in circumstances of high ambulance demand
7. Ambulance Victoria and ESTA explore feasibility of workflows and technical systems to allow real-time transfers of 000 callers to Triage Services