In my dealing with emergency services many people report a fear of the coroner (see Eburn, M. and Dovers, S., ‘Australian wildfire litigation’ (2012) 21(5) International Journal of Wildland Fire 488-497).  The argument ‘we’ll you have to explain that to the coroner’ is the ultimate threat when person A wants person B, or the organisation, to change a policy or procedure.  No doubt appearing before a coroner and having one’s decisions reviewed does not appear in anyone’s list of ‘top 100 fun things to do’ and preparing for a hearing that may involve several days in court and many more hours of putting together documents and submissions takes up significant resources; but even where there are poor outcomes it does not follow that the service or members will be subject to criticism.  In my earlier post, Coronial inquest into death of NSWFR firefighter (2 March 2018) I review an inquest and inquiry into the response to a fire that lead to the death of a firefighter.

In Inquest Into The Death Of Elfriede Adele Tremethick [2018] ACTCD 3 (27 February 2018) the inquest was held in the Coroners Court of the Australian Capital Territory and involved a review of the response by ACT Ambulance.

Ms Tremethick was an 85 year old woman with a prior history of congestive heart failure.  On 21 October 2016 she fell down a short ramp at home.  She did not have a prior history of falls.  She suffered a lacerated forearm with a possible fracture.  The ACT Ambulance Service (“ACTAS”) attended ([1]).

On arrival, Ms Tremethick was ‘conscious, alert and responsive, and she was lying face down at the bottom of the ramp with her legs elevated’. Treating paramedics administered methoxyflurane for pain relief. Ms Tremethick ([2]-[3]):

…became non-compliant and said she had difficulty breathing.  Ms Tremethick was sat upright on the stretcher but she developed fulminant pulmonary oedema and gastric regurgitation, and she was administered high flow oxygen. At the time Ms Tremethick aspirated, the paramedics held a discussion as to whether she should have been intubated, and a decision appears to have been made not do to so given the circumstances.

Shortly after this Ms Tremethick lost consciousness and stopped breathing and became pulseless.  The paramedics commenced cardio-pulmonary resuscitation and manual ventilation, but despite ongoing treatment and emergency transport to Calvary Hospital Ms Tremethick was unable to be revived in the ambulance and she was formally declared life extinct at Calvary Hospital.

The cause of death (at [4]) was ‘asphyxia caused by inhaled vomitus, with left ventricular hypertrophy being a condition which contributed to death without being directly related to the actual cause’.

The decision not to intubate was controversial.  The coroner wanted to review ‘the appropriateness of the treatment provided to Ms Tremethick by ACT Ambulance Officers’.  Copies of the ACTAS records were obtained and reviewed, at the Coroner’s request, by Professor Johan Duflou, a consulting forensic pathologist ([5]).

The professor’s opinion ([5]) was that Ms Tremethick’s position, ‘lying face down at the bottom of the ramp with her legs elevated’, would have aggravated her underlying heart condition

… as a result of increased venous return.  Additionally, such a position could be expected to hamper unaided breathing.  Ms Tremethick’s cardiac function probably deteriorated while in that position, arguably with the contributory effect of pain and stress as a result of the fall and injury sustained, and she had an acute exacerbation of congestive heart failure with the development of acute pulmonary oedema.  Possibly the concurrent administration of methoxyflurane could have contributed to Ms Tremethick’s deteriorating cardiorespiratory function at this time.  On identification of Ms Tremethick’s deterioration, she was appropriately sat upright, but likely by this time she was in extremis, and she regurgitated and aspirated gastric contents while having a cardiorespiratory arrest…

The reason for Ms Tremethick’s sudden deterioration was in the form of a sudden exacerbation of her congestive heart failure with development of acute pulmonary oedema, with regurgitation and aspiration occurring in the immediate perimortem period as an agonal phenomenon, and not as a primary event.

There were issues with respect to the treatment offered but both Professor Duflou and the Coroner thought that the issues identified by ACTAS (at [6]), relating to documentation, initial assessment, communication between the paramedics, the decision not to intubate and the decision to continue with response driving after CPR had been terminated, did not contribute to Ms Tremethick’s death.

ACTAS (like NSWFR in the earlier case under discussion) reported to the Coroner steps it had taken in response to Ms Tremethick’s death. At [9]:

Specific steps taken to address the system and process issues arising from this incident were as follows:

a. Key topics arising from Ms Tremethick’s death were covered during the Paramedic clinical in-service training program in 2017, including revision of cardiac arrest management, teamwork and communication processes when multiple officers are on scene, review of advanced airway management, and an advanced airway management simulation exercise.

b. ACTAS’s policy around termination of resuscitation and management of deceased persons is being reviewed and is in the process of being updated. Relevant to Ms Tremethick’s case, the policy will reinforce current practice as to the circumstances under which paramedics should cease resuscitation and that urgent transport to an Emergency Department is not warranted after a patient has died.

c. A systemic review of airway management practices is underway for consideration by the ACTAS Clinical Advisory Committee in March 2018. Relevant to Ms Tremethick’s case, the draft document reiterates the importance of placing an advanced airway in patients in cardiac arrest.

The Coroner noted (at [11]) ‘that while on the facts of this case the decision not to intubate Ms Tremethick probably made no difference to her outcome, it is foreseeable that in other cases such a decision could directly affect the outcome for a patient’ but there was no need for a formal public hearing given the response that had been implemented by ACTAS.

With respect to the paramedics that attended, the Coroner said (at [7]) ‘While the aspects of suboptimal care identified by Professor Duflou and ACTAS are generally of concern, I accept the opinion of Professor Duflou that it is unlikely that these contributed to Ms Tremethick’s death.  In those circumstances, I make no comments adverse to ACTAS, or the paramedics who attended on Ms Tremethick on the day of her death’.


‘No comments adverse…’ is not a glowing commendation (such as that seen in the inquiry into the Cobar fire (Coronial inquest into death of NSWFR firefighter (2 March 2018)) but equally it’s not the consequences people often fear from a coroner.  A coroner can’t determine issues of legal rights, they can’t determine that someone was, or was not negligent or that someone is, or is not, guilty of a criminal offence.  A coroner can’t make orders to adjust people’s legal rights.  Only a court of law can do those things.

This coroner reviewed the material.  There were issues of concern in the treatment provided but these were identified and are being addressed.  Again the value of the inquiry is to reassure the public and the family of the deceased that these matters have been identified and are being addressed rather than leave people to suspect a ‘white wash’ or agencies investigating themselves.  Whether or not there’s a better process to achieve that outcome is a different matter  (see Eburn, M. & Dovers, S. Discussion paper: Learning for emergency services, looking for a new approach (Bushfire and Natural Hazards CRC, 2016); or for the ‘executive summary’ Eburn, M and Dovers, S ‘Reviewing high-risk and high-consequence decisions: finding a safer way’ (2017) 32(4) Australian Journal of Emergency Management 26-29).