Finding into death of Veronica Therese Campbell
Deceased
Veronica Therese Campbell
Demographics
38y, female
Date of death
2008-12-31
Finding date
2010-11-05
Cause of death
complications following a ruptured ectopic pregnancy
AI-generated summary
Veronica Campbell, age 38, died on 31 December 2008 from complications of a ruptured ectopic pregnancy. She presented to Cobram District Hospital with severe pain and was diagnosed with a possible ectopic pregnancy requiring urgent transfer to Goulburn Valley Hospital. Critical failures occurred in the ambulance transfer: the case was initially prioritized as Code 2 (non-urgent), and despite multiple requests from hospital staff to upgrade to Code 1 priority when her condition deteriorated (hypotension, anaemia, blood loss), dispatchers failed to record clinical information or respond appropriately. Significant delays resulted—the initial ambulance took 1.5 hours to reach Cobram, then time was lost awaiting MICA and Air Ambulance. The coroner found the death preventable; surgery within 1–2 hours would have saved her life. Key system failures included inadequate ambulance dispatch staffing, poor communication, failure to record clinical updates, resource constraints, and lack of blood products at the rural hospital.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- initial dispatch as Code 2 (non-urgent) priority despite ectopic pregnancy diagnosis
- ambulance resource constraints in Shepparton region with only two dispatchers
- failure to record clinical information on dispatch case card despite multiple calls from hospital
- failure to upgrade ambulance priority despite hospital staff's repeated requests
- communication failures between ambulance dispatch centre and hospital staff
- dispatcher fatigue and high workload at dispatch centre
- lack of whole blood products at rural hospital
- limited surgical and anaesthetic facilities at Cobram District Hospital
- delays in escalation and use of appropriate retrieval services
- decision to use Air Ambulance rather than road transport with MICA ambulance
Coroner's recommendations
- Hospital facility descriptions summarising the facilities available at rural hospitals should be created and utilised by Ambulance Victoria, with descriptions readily available to dispatchers
- The term 'emergency department' should not be used for small rural hospitals with only urgent care facilities
- Ambulance Victoria should increase the number of ambulances available in the Shepparton region on evening and night shifts
- Ambulance Victoria should undertake a complete systems review to determine the optimum ratio of dispatching staff to ambulance vehicles on each shift
- Staffing must be at a level sufficient to enable staff to enter information on the Medical Dispatching System or New Case Card system
- Staffing should be at a level that ensures dispatchers and call takers are able to take appropriate breaks
- Clear lines of responsibility and decision-making should be mapped out between Ambulance Victoria and hospitals regarding delivery of clinical information and requests for priority upgrades
- Where there is disagreement or the dispatcher is considering not providing an upgrade, there should be a structured decision-making process that includes communicating the decision to the treating doctor
- Information on the response time of Air Ambulance needs to be available to dispatchers before a decision to use Air Ambulance is made, and assessment should be mandatory when patient transport is time critical
- Ambulance officers should consult the treating doctor if a decision may result in a delay in transport
- Ambulance Victoria and the Victorian Government should develop a viable method of providing blood products in emergencies in rural communities
Full text
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