Coronial
VIChome

Finding into death of Martin Barlow

Deceased

Martin Barlow

Demographics

67y, male

Coroner

Coroner Audrey Jamieson

Date of death

2022-08-06

Finding date

2025-02-14

Cause of death

Head injuries sustained in falls

AI-generated summary

Martin Barlow, 67, died from head injuries sustained in two falls on 5 August 2022 while intoxicated (BAC 0.17 g/100mL). He suffered subarachnoid haemorrhage and subdural haemorrhage. After Ms Burrell called emergency services at 11pm, Ambulance Victoria experienced a 4+ hour delay before arrival at 3:48am, finding him in cardiac arrest. While causation cannot be definitively established, the coroner found his best chance of survival required early hospital transport and neurosurgical assessment. The delay was attributable to systemic issues: 40-60% of the metropolitan fleet was ramped at hospitals with 3-4 hour delays, only 6% available for Code 1 events, and a Code Green (medium service impact) was in effect. Alcohol consumption and previous stroke were contributing factors. The case highlights broader Ambulance Victoria performance deficits post-COVID-19.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

emergency medicineparamedicineneurosurgeryforensic medicine

Error types

delaysystemcommunication

Drugs involved

alcoholclopidogrel

Clinical conditions

subarachnoid haemorrhagesubdural haemorrhagecerebrovascular accident (previous)head injurycardiac arrestasystolehepatic steatosischronic obstructive pulmonary disease

Procedures

cardiopulmonary resuscitation

Contributing factors

  • Intoxication with alcohol (BAC 0.17 g/100mL)
  • History of cerebrovascular accident/stroke with ongoing light-headedness
  • Clopidogrel use (antiplatelet medication)
  • Chronic lung disease and heavy smoking history
  • Delayed ambulance response (>4 hours)
  • Ambulance fleet unavailability due to hospital ramping
  • Code Green in effect on the night (medium service impact)
  • Miscommunications with emergency call takers

Coroner's recommendations

  1. Progress the TEC2 program (Timely Emergency Care 2) to translate and implement national and international best evidence and practices to enhance Ambulance/ED patient flow strategies to improve access and safety
  2. Department of Health and Ambulance Victoria to consult with peak bodies including the Council of Ambulance Authorities, the Ambulance Association of Chief Executives and Paramedic Chiefs of Canada regarding ambulance/ED patient flow improvements
  3. Address broader system-wide issues of hospital access block and ambulance fleet availability to enable Ambulance Victoria to meet Key Performance Indicators
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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