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Coronial inquest of preventable death in Regional NSW

Posted on 28th May 2021
Catherine Henry Lawyers
Catherine Henry Lawyers

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Coronial inquest of preventable death in Regional NSW

Our client’s son, Thomas, tragically died in 2015 after punching a window at a property in Barrington on the NSW mid coast.

Paramedics called a helicopter 10 minutes after arriving on scene. Instead of being transported by ambulance to Gloucester Hospital (about 10 minutes away) for stabilising treatment while waiting for the helicopter, paramedics waited at the property for over an hour.

Shortly after the arrival of the helicopter, Thomas suffered a cardiac arrest. He was resuscitated and then transported to Gloucester Hospital (by road in the ambulance). He arrived there more than two hours after the ambulance first arrived on the scene. He was stabilised at Gloucester and then left in the helicopter towards Taree (for blood and fuel) at about 1.30pm. Tragically, he died en-route.

NSW Health trauma policies and procedures tested

The inquest looked at the NSW Trauma Services Plan and related protocols and guidelines – specifically the relationship between these protocols and the inclusion (or exclusion) of local hospitals in trauma management. Other issues at the heart of this inquest included resourcing of the health system and emergency response, and communications and coordination of rescue efforts.

We helped Thomas’s family put to the coroner that the plans and protocols were not properly followed. Thomas should have been taken to the local hospital straight away to rendezvous with the helicopter, rather than waiting for its arrival at the property. The protocols state that transportation of patients should not be delayed awaiting the arrival of a helicopter or medical team; paramedics should depart the scene for hospital and liaise with the medical team to arrange an appropriate rendezvous point if required.

What would have been the outcome if the paramedics had followed protocol and driven Thomas to the local hospital?

If the paramedics had followed the T1 protocol, including the Transport Destination Matrix set out in the protocol, the ambulance could (and should) have been on the road by 10.18am at the latest and would have arrived at Gloucester hospital by approximately 10.30am.

Thomas would then have been in a hospital environment where treatment could have stabilised him. In a hospital there would have been access to better facilities than in the ambulance at the property, including doctors, suturing material, blood and blood products, and pain relief. This could have potentially avoided the first cardiac arrest and it is likely that Thomas would have been ready for transport direct to the John Hunter Hospital earlier than 1.30pm and therefore his likely outcome would have been improved.

Had this occurred, Thomas’s family may also have avoided significant trauma in knowing that all was done that could have been done to try and save Thomas rather than being left to wonder “what if?”.

A family’s ability to have their say

Like many of the clients we represent in medical negligence cases or inquests, Thomas’s family wanted support to be able to have an opportunity to have their views heard on issues such as the qualifications and training of ambulance personnel in dealing with major trauma cases as well as the need for directions to have blood supplies and appropriate pain medication in every ambulance. They want practices changed so that what they have been through does not happen to another family.

Coronial inquests in regional areas

Problems in resourcing of inquests and other judicial matters are also highlighted by this inquest. Sadly, Thomas died more than four years ago. The inquest did not start until one year ago when two days of hearings were held in Taree. The final three days of the hearing took place a further 12 months later. The coroner is not expected to give his findings until about October 2019.

It is concerning that it takes this long for proceedings to occur outside of capital cities. We don’t have enough District Court judges or coroners working in regional Australia.

Representation at inquests

If you are involved in an inquest and need guidance in properly presenting your point of view, please do not hesitate to talk to our caring, expert team. We can help you to argue for changes that prevent tragic events from happening again to others. To confidentially discuss your needs call us on 1800 874 949 or fill in the form below, and we will be in touch.

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