TITLE OF COURT: Coroner’s Court

JURISDICTION: Darwin

FILE NO(s): D0122/2003

DELIVERED ON: 5 August 2004

DELIVERED AT: Darwin

HEARING DATE(s): 3,4 August 2004

FINDING OF: Mr Greg Cavanagh S.M.

CATCHWORDS:
CORONERS: Inquest, St John Ambulance, ambulance dispatch, refusal to send ambulance

REPRESENTATION:

Counsel:
Assisting: Ms Elizabeth Morris
St John Ambulance: Mr Richard Bruxner

Judgment category classification: B
Judgement ID number: [2004] NTMC 059
Number of paragraphs: 38
Number of pages: 15

IN THE CORONERS COURT
AT DARWIN IN THE NORTHERN
TERRITORY OF AUSTRALIA

No. D0122/2003
In the matter of an Inquest into the death of

STEPHEN JOHN POWER
ON 5 SEPTEMBER 2003
AT 13/29 VICTORIA DRIVE, GRAY

FINDINGS

(Delivered 5 August 2004)

Mr GREG CAVANAGH:

The nature and scope of the inquest

1. Stephen John Power ("the deceased") died at some time between 1200 hours and 1545 hours on Friday 5 September 2003. He was at his home at 13/29 Victoria Drive Gray. For reasons that follow, the death was unexpected and, as such, was a "reportable death" within the meaning of s12(1) of the Coroners Act ("the Act"). Pursuant to my discretion under s15(2) of the Act, I held a public Inquest into the death of the deceased.

2. Section 34(1) of the Act details the matters that an investigating coroner is required to find during the course of an inquest into a death. The section provides:
"(1) A coroner investigating –

(a) a death shall, if possible, find –
(i) the identity of the deceased person;
(ii) the time and place of death;
(iii) the cause of death;
(iv) the particulars needed to register the death under the Births, Deaths and Marriages Registration Act; and
(v) any relevant circumstances concerning the death; or …

3. Section 34(2) of the Act operates to extend my function as follows:
"(2) A coroner may comment on a matter, including public health or safety or the administration of justice, connected with the death or disaster being investigated."
4. The duties and discretions set out in subsections 34(1) and (2) are enlarged by s35 of the Act, which provides as follows:
"(1) A coroner may report to the Attorney-General on a death or disaster investigated by the coroner.
"(2) A coroner may make recommendations to the Attorney-General on a matter, including public health or safety or the administration of justice connected with a death or disaster investigated by the coroner."
5. The public Inquest in this matter was heard at the Darwin Magistrates Court on 3 and 4 August 2004. Counsel assisting me was Deputy Coroner, Ms Elizabeth Morris. Mr Richard Bruxner sought and was granted leave to appear and represent the St Johns Ambulance Service. The deceased’s family were in attendance throughout the proceedings.
6. Evidence was called from Brevet Sergeant Anne Lade, Cynthia Baird, Robert Langlands, Coralie Holland, Karen Joyner, Dr Terence Sinton and Trevor Sellick. Exhibits tendered included the investigation brief, medication found in the deceased’s unit, the deceased’s birth certificate, and St Johns Ambulance documentation and manuals.
Formal findings

7. The mandatory findings pursuant to s34(1) of the Act are as follow.
(1) The identity of the deceased was Stephen John Power.
(2) The time and place of death was at some time between 1200 and 1545 hours on Friday 5 September 2003 at 13/29 Victoria Street, Gray in the Northern Territory of Australia.
(3) The cause of the death was lobar pneumonia of the left lung.
(4) The particulars required to register the death are:
(i) the deceased was male;
(ii) the deceased was Caucasian;
(iii) the death was reported to the Coroner;
(iv) the cause of death was confirmed by post-mortem examination;
(v) the cause of the death is as described in paragraph (3) above;
(vi) the pathologist viewed the body after death;
(vii) the pathologist was Dr Terence John Sinton of the Royal Darwin Hospital;
(viii) the father of the deceased was William John Power and the mother was Margaret Power (nee Boxer);
(ix) the usual address of the deceased was 13/29 Victoria Drive, Gray in the Northern Territory of Australia; and
(x) the deceased was unemployed.

8. The deceased was born in Croydon, Victoria on the 29th of June 1968. The deceased resided at Unit 13, 29 Victoria Drive, Gray and lived in an on and off again relationship with Cynthia Baird. They had been together some six months. He had been previously married and had a ten year old daughter.
9. The deceased had been unwell for a period of about a week prior to his death, coughing excessively and complaining of a sore side. Ms Baird stated that he refused to go to the Doctor. A check with the deceased’s medical records held at the Palmerston Medical Clinic show that the deceased saw Dr. Singh on Wednesday 27th August 2003 with a recurrence of boils. He was prescribed Flucloxacillin (Staphylex) an antibiotic and Bactoban ointment for an abrasion he had to the left knee. An interview with Dr Singh is included in the brief of evidence. The script was not filled until the following week.
10. In June 2003 the deceased assaulted Ms Baird and he was charged with Aggravated Assault and a Domestic Violence Order was taken out against him for 12 months. This was a full non –contact order.
11. On Wednesday 3rd September 2003 the deceased and Ms Baird went to the Darwin Magistrates Court to have the Domestic Violence Order varied. Ms Baird stated that the deceased was very ill and that she had to assist him with walking (the matter of the variation of the order was adjourned until Friday 5th September). After attending Court the deceased and Ms Baird returned to Palmerston on the bus. Ms Baird went to the shops and the deceased stated that he was going to the Doctor, however, investigations revealed that the deceased did not go to the Doctor on that date but he did have the script filled (i.e the script that he had received the previous week from Dr. Singh). The deceased attended the Chemmart Pharmacy at Palmerston and received the Staphylex and the Bactoban. Ms Baird believed erroneously that, as he had medication to take, that he must have been to the Doctor.
12. The deceased returned to the unit at Victoria Drive and Ms Baird went to the tavern and returned home later. In her statement to the Coronial investigator Ms Baird described the deceased on Thursday 4th September 2003 as follows:
“He was still crook he hadn’t changed. I knew he had tablets because I saw him take one. The tablets he kept in the fridge. Steve spent the day watching TV. He seemed O.K., although still crook. He eventually went to the room to lay down. His breathing was really laboured at the time. This was the same all through the night.”
13. Ms Baird was concerned for the deceased during the Thursday so went to the phone box at the Gray shops, and called 000 at 1554 hours asking for the Ambulance. Ms Baird spoke with the call taker, Coralie Holland but an ambulance was not sent.
14. Ms Holland gave evidence before me. She has been involved with St John Amubulance since a student volunteer in 1997, and was currently a part time employee. Her duties as an Emergency Medical Dispatcher (“EMD”) included taking all calls and dispatching ambulances referred from the Telstra operator. She had a recollection of the call from Ms Baird.
15. A tape recording of the actual calls of Ms Baird was played in court before me, during the evidence of Brevet Sergeant Lade. The tape forms part of the investigation brief, and was obtained from the Joint Emergency Services Communication Centre (“JESCC”) by Sergeant Lade.
16. During that call it is clear from the evidence that Ms Holland did not think that the illness of the deceased was a serious one.
Amb Off: So what’s he doing? He’s breathing OK?
Caller: No,he’s got a rattly chest.
Amb Off: He’s got a cough and things like that. He’s just got, he’s got a cold?
Caller: Yeh, but it’s pretty bad. It’s more…uh..oh my…uh…I can’t explain it.
Amb Off: Ok, so Cynthia have you tried taking him up to the doctors, up to the clinic?
17. Ms Holland acknowledged in her evidence that the following exchange occurred, but that at the time, she did not hear that the deceased had to be helped to the toilet.
Caller: Well, he won’t even move when I ask him. That’s the reason why I…
Amb Off: But he’s obviously moving enough, he’s getting up and going to the toilet and things like that.
Caller: Well I’ve got to help him there.
Amb Off: Yeah, Cynthia I think may be you need to just get him to see his doctor again and if he doesn’t want to see his doctor he certainly not going to want to see the ambulance….
18. Ms Holland stated that had she heard the comment about assisting the deceased to the toilet, she would have asked more questions. In hindsight, if Ms Holland had any idea of the extent of the illness of the deceased, she would have despatched an ambulance. However, given the information she had at the time, she did not think she made the wrong call. Ms Holland confirmed that it was “accepted practice not to send an ambulance to everything.” She advised that up to that day, the only cross cultural training she had had, was during her general training some years earlier, and was not specific to working as a dispatcher.
19. Senior St Johns Ambulance officer (viz Mr Sellick) gave evidence that an ambulance should have been sent as a result of this call to operator Holland
20. On Friday 5th September 2003 the deceased woke at about 11:30 hours and Ms Baird had to help him get up and get dressed and he then lay on the couch. In her interview Ms Baird stated:
“He said to me he felt wasted. Steve was coughing and having a lot of trouble breathing. I asked him about his tablets but he said they were making him feel sick and weak. Sometime after I called for an ambulance. Steve was looking so weak and crook. I was worried about him”.
21. At 14:21 hours Ms Baird phoned 000 again from the Gray shops and spoke with the EMD Karen Joyner but an ambulance was not sent. Ms Baird also called a family friend. When she returned she found that the deceased was on the bed and not breathing and so she again called 000 using the deceased’s mobile phone. This call was received at 15:22 hours again by Karen Joyner. Ms Baird also called out to a neighbour – Robert Alan Langlands who came to the unit. He assisted Ms Baird, instructed by Ms Joyner how to do CPR and mouth to mouth. An ambulance was dispatched and arrived at Victoria Drive at 1535 hours but no signs of life were observed and resuscitation was ceased at 1545 hours.
22. General Duties Police attended as did CIB, Forensic and the Coronial Investigation Unit member, Brevet Sergeant Anne Lade.
23. Dr Terence John Sinton performed an autopsy on the 8th of September and the cause of death given was left lower lobe pneumonia. He gave evidence before me. In his opinion, the deceased’s chances of surviving his pneumonia would have been enhanced by receiving appropriate treatment, even 24 hours prior to his death.
24. The death was subsequently the subject of investigation by the Coronial Investigation Unit Brevet Sergeant Anne Lade. I find that her investigation was thorough, timely, competent and professional.
25. As previously stated, he three calls to 000 were recorded, and a tape of that recording was tendered. The first two calls was played during evidence. The transcript of the second call is as follows:
“Amb Off: Ambulance
Operator: 965236. Thank you
Amb Off: Thank you. Hello Ambulance.
Caller: Yeh, hi, I rang last night about a bloke that he’s very sick and he’s still in the same way as he was last night. So more likely he’s getting more worse.
Amb Off: In what way? What’s wrong with him to start with?
Caller: Well he just caught the flu but this is just bad, I can’t even tell …
Amb Off: Ok isn’t this the one with the stick through his hand?
Caller: No, no, no, no, no
Amb Off: No, he’s got the flu?
Caller: 12, uh, about a week or so now.
Amb Off: Yeh, and where is he?
Caller: He’s at number 13 / 29
Amb Off: 13 / 29 he’s at Victoria Drive is he?
Caller: Yes.
Amb Off: Ok.
Caller: And his name is Stephen Power.
Amb Off: Stephen Power. How old is he?
Caller: 34 uh 36, 35 – 36 something like that.
Amb Off: Yeh, so he had a cold for the last week …
Caller: Yeh um, but he’s pretty bad ah. He can’t even breath or ……… like that.
Amb Off: Oh, and what he’s been like that for the whole week?
Caller: Yes.
Amb Off: What’s your name mame?
Caller: My name is Cynthia Baird.
Amb Off: Ok Cynthia why hasn’t he gone up to the doctor?
Caller: Well, he went up there and he got the tablets from them but the tablets that they gave him …

Amb Off: And he, that’s right he only had one yesterday didn’t he?
Caller: No, no he had about 4 of them.
Amb Off: Yeh.
Caller: Because every half an hour the tablet is not doing him any good.
Amb Off: Ok, so he needs to go back to the doctor. When was he give the tablet. When was he given the tablet.
Caller: On Wednesday, I think. But I really, really really would like to put a ………………. take him to the hospital.
Amb Off: Just hang on one moment.
Unidentified voice: car 6 2
Amb Off: You there?
Caller: Yeh.
Amb Off: He went to the doctor up at the clinic did he?
Caller: Yes
Amb Off: And they’ve prescribed tablets for him?
Caller: Yeh, but it’s not doing him any good.
Amb Off: Ok, they take a while to start to working.
Caller: Yeh, but its just making him more drowsy and he can’t even walk to the toilet. I have got to help him and I’m not a baby sitter.
Amb Off: And were not a taxi service? Why do you think he requires a taxi, uh an ambulance?
Caller: I was just wondering if, that just take him to the hospital and get it over and done with it.
Amb Off: Ok. Cynthia is there some reason Stephen can’t get in a taxi or get one of his mates pick him up and take him up there?
Caller: There is no mates for him, he hasn’t got a mate with a car or nothing, not at all.
Amb Off: Alright, so what’s wrong with a taxi?
Caller: Well, put it this way, we haven’t got any money.
Amb Off: So how are you going to pay for an ambulance bill. You know $300 - $400 worth.
Caller: Well right about now we haven’t got any money but come Monday when I get my money I’ll pay for it.
Amb Off: Ok, well Cynthia I personally think that if he’s not getting any better he should go back to the doctor and see the doctor up at the clinic. Ok, he’s been through 5 medications for it, do you know what he’s taken?
Caller: No.
Amb Off: You don’t know what he’s taken.
Caller: No.
Amb Off: No. Ok, I really suggest you go back and see his doctor and tell him that it’s not helping at all.
Caller: Help ah. I thought you guys are there to help.
Amb Off: Cynthia, we’re an emergency service, we’re not a taxi service or a clinic service.
Caller: Yeh, well it is an emergency.
Amb Off: Yeh, that’s according to you. Is Stephen able to come to the phone and speak to me?
Caller: HE CAN’T, HE CAN’T, that’s what I’m saying he can’t.
Amb Off: Yeh.
Caller: He can’t even walk anywhere.
Amb Off: You only got the medication yesterday didn’t he?
Caller: Uh. Today is Friday and that was on Wednesday when he got … he had to go to the court house to deal with things, but he barely made it there.
Amb Off: The thing is Cynthia he did make it there and he’s had it for over a week.
Caller: Yeh well I …
Amb Off: He has medication for it.
Caller: Yeh, but I had to help him.
Amb Off: So what do you mean you had to help him get to the court house.
Caller: As in nearly carrying him on my back.
Amb Off: How did you get him to the court house?
Caller: We caught a bus.
Amb Off: Ok, I just need you to hold the line for one minute for me.
Amb Off: Ambulance good afternoon.
Unidentified voice: Are you busy?
Amb Off: Yeh, I am a little bit .
Unidentified voice: Oh alright, were still sitting at the hospital.
Amb Off: Who’s we?
Unidentified voice: Me and Matt.
Amb Off: Who?
Unidentified voice: Me and Matt.
Amb Off: Who is it?
Unidentified voice: It’s Kevin.
Amb Off: Uh, ok hold on a minute.
Unidentified voice: Ok
Amb Off: Bugger, uh, now the radio is busy. Car 2 6 send. Roger car 26 mark your case card ANR your (inaudible) return is 1417. Sorry Kevin why are you still sitting at the hospital?
Unidentified voice: Uh, they had a second patient and that patient is not ready.
Amb Off: Oh why didn’t they ring us back and bloody well tell us and why not organise it when their bloody doing it.
Unidentified voice: Karen, your having a bad day.
Amb Off: It just got busy suddenly and I’ve got this looser on the line, that this 34 year old thing had a flu for a week, he was prescribed medication, he’s not getting any better, went to court on Wednesday and she had to literally carry him. And I don’t have an ambulance, well I do now, but that’s at Casuarina and I’m not sending them all the way out to bloody Palmerston.
Unidentified voice: Yeh.
Amb Off: Yeh, well I’ll make a note. No worries.
Unidentified voice: Bye
Amb Off: See ya.
Amb Off: You there Cynthia?
Caller: Yes.
Amb Off: Yeh, so what are you going to do for him?
Caller: I just want him to get to the hospital and so I don’t have to worry about him any more. I mean like you know as in getting stressed out, which I am, stressed out right about now.
Amb Off: Yeh.
Caller: I just want him ….
Amb Off: I can’t work out why you require an ambulance for him, it just sounds like your trying to get rid of him.
Caller: No, no, no I’m not trying to get rid of him, I just want him to get better.
Amb Off: Yeh.
Caller: And that’s about it.
Amb Off: Ok.
Caller: Cause I don’t want to loose him, because I lost my mother and I lost my grandmother and …..
Amb Off: We’ve all lost family members.
Caller: FUCK THIS (hang up)”
It should be noted that Cynthia Baird stayed on the telephone for over eight minutes trying to get an ambulance sent.
26. Ms Joyner has been involved with St Johns Ambulance since 1996, starting as a volunteer. Ms Joyner was asked in an interview with Sergeant Lade: (soon after the death):
Lade: Having listened to the tape again and read the transcript are you satisfied with how you dealt with the call?
Joyner: Yes
Lade: Are you satisfied with the way that, there were questions that you asked her?
Joyner: Yes
Lade: Alright, in relation to the, there’s an obvious break on the phone or when you put her on hold and then you speak to someone else, there’s a paragraph where you make some comments about eh caller, is there anything you wish to say about that?
Joyner: It was a work colleague I was speaking to and has full understanding of calls like this that we receive all the time, the caller herself didn’t seem motivated enough to do anything with the patient, didn’t appear to want to help him herself apart from ringing an ambulance, she didn’t appear prepared to do anything else herself.
27. Ms Joyner told me in court when asked if she was still satisfied with her response, “no…I shouldn’t have argued the point, I should have just sent an ambulance.”
28. Ms Joyner told me she had just come from four days off, and was four hours into a twelve hour shift. It had been according to her a “very busy morning”. She did however recall a short conversation that she had with Ms Holland the previous day about the deceased. The extent being that the deceased had had a cold for a week and didn’t want an ambulance.
29. At the start of the call to Ms Joyner, there was not an available ambulance to attend, but one did become available during the course of the call.
30. Ms Joyner agreed that she had basically stopped listening to Ms Baird and this attitude had affected her response. She also agreed that the questions she asked in relation to Ms Baird’s ability to pay for the ambulance service were not part of any policy or of the Advanced Medical Priority Dispatch System (known during the Inquest as the Pro Q A).
31. In my view, Ms Joyner was rude and inconsiderate in her dealing with Ms Baird during this phone call. She maintains that Ms Baird’s “level of concern” was not there and that it was a callers “insistence” that would result in the dispatch of an Ambulance. I can make no criticism of Ms Baird’s attempt to obtain ambulance assistance for Mr Power. The phone call was some eight minutes long and Ms Baird repeatedly asked for an ambulance. Ms Joyner’s decision not to send an ambulance was wrong and ill considered; she was dismissive of Ms Baird and her legitimate requests.
32. Trevor Sellick, who is the Operations Manager of the Northern Region of St John’s, and has been for some six years, also gave evidence. His statement was tendered. He quite properly conceded that St John’s response to Ms Baird’s calls for assistance were not acceptable at all. In his view asking a caller to pursue another method of transport to hospital was “dissuading” them from attempting to access the ambulance service.
33. On behalf of St Johns Ambulance he expressed his deep regret to the deceased’s family for the failings of the system.
34. Fortunately as an institution, St John’s Ambulance have reacted to what occurred quickly and appropriately. They are to be commended. Much has been done to improve that system since the deceased’s death. St John have implemented a policy that EMD’s are not to fail to dispatch an ambulance except in the clearest of circumstances. This has eliminated much of the discretion or judgment of the dispatcher.
35. The staff were counselled, and all communications officers participated in a workshop, which included cross cultural training. The procedures manual was updated (a copy was tendered) and formed part of training.
36. St Johns have installed their own recording apparatus which will allow them easier access to 000 call recordings. This will allow calls to be monitored and reviewed from a performance basis.
37. Given the recognition by St Johns Ambulance of the failings in their system, and their efforts to rectify and improve the system, many of the recommendations that I would have made, are redundant. They would have included the inclusion of ongoing cross cultural training, especially concentrating on Aboriginal language and barriers to accessing services, the provision of ongoing communication training, and the introduction of revised procedures manuals.
38. I find that had an Ambulance been sent on the Thursday then the deceased may well have received the necessary treatment that could have saved his life. Sadly in all probability, by the time of the call on Friday, the deceased may already have passed away.

Dated this

______________________________
GREG CAVANAGH
Territory Coroner