The South Australian Deputy State Coroner held an inquest into the deaths of three people whose condition deteriorated whilst they were waiting in ambulances pending admission to a hospital emergency department (Inquest into the Deaths of Anna Vincenza Panella, Bernard Anthony Skeffington and Graham Henry Jessett [2025] SACC 21). The coroner was of course looking specifically at the factors that contributed to these deaths, but he acknowledged that the fact of ambulance ramping was widespread and these three were a representative sample of ‘of other people who have died or have nearly died on the ramp’ ([92]).

The role of the coroner

The role of the coroner is to investigate reportable deaths and to set out ‘out as far as has been ascertained the cause and circumstances of the event that was the subject of the inquest’ (Coroners Act 2003 (SA) s 25(1)). The Court (s 25(2)):

… may add to its findings any recommendation that, in the opinion of the Court—

(a) might prevent, or reduce the likelihood of, a recurrence of an event similar to the event that was the subject of the inquest; or

(b) relates to a matter arising from the inquest, including (but not limited to) matters concerning—

(i) the quality of care, treatment and supervision of the dead person prior to death; and

(ii) public health or safety; and

(iii) the administration of justice,

and is, in the circumstances, an appropriate matter on which to make a recommendation.

The Court ‘must not make any finding, or suggestion, of criminal or civil liability’ (s 25(3)).  Many people express fear of the coroner as if appearing before the coroner is one of the worst things that can happen to a person.  As s 25(3) makes clear a coroner cannot determine that anyone is guilty of a crime or was negligent. As a reading of the findings being reported here shows, coroners are mindful that people are working within a system and adverse outcomes are not necessarily due to a lack of care. Coroner White, in this case was very careful not to blame anyone for these outcomes but to recognise the goodwill and extraordinary effort that all the doctors, paramedics, nurses and health staff put into trying to care for their patients (see also First aid and paramedic care – and coroners are not out to get you (December 1, 2018)).

The problem of ramping

In this inquest the coroner recognised that ambulance ramping was symptomatic of significant issues affecting the health sector generally.  He said (at [92] emphasis added):

In order to have proper regard to the coronial jurisdiction, I must use the broad evidence I heard to identify the cause and circumstances of the deaths investigated and whether there are any recommendations which might assist to prevent future deaths. With due respect to others who may think otherwise, I believe an aspirational recommendation to end ramping would be unhelpful …

Merely recommending that the state take steps to end ramping would not be helpful given the state is trying to manage hospital loads, and if there was a simple fix, it would already have been implemented.  His Honour said (at [103]-[106]):

At its most basic, ramping simply refers to the practice of having patients wait in ambulances outside the Departments of hospitals until there is enough space inside to allow them entry. That simple concept masks a much more complex scenario which is unveiled by asking the question ‘what causes ramping?’. All witnesses were quick to explain that, while ramping occurs at the door of the Department, it is actually caused initially by access block, which is contributed to by exit block, which itself is caused by resource issues spread across the entire health system.

… Access block is the inability to move patients from the Department into hospital wards, resulting in patients simply waiting in the Department long after they have been stabilised and treatment commenced, and they are no longer in need of emergency-level care. Exit block is the inability to move patients from wards out into the community, resulting in patients simply waiting in hospital wards well after they no longer need hospital-level care. Exit block contributes to access block which causes overcrowding in the Department. With all suitable treatment spaces taken up by patients, newly arriving patients cannot progress into the Department. They will therefore wait either in the waiting room or in an ambulance outside the hospital.

Access and exit block issues themselves appear to be exacerbated by deficits in residential aged care and disability care facilities in the community, as well as the limited number of mental health treatment spaces in hospitals. … The consequence of community placement limitations is that patients who would otherwise be released from hospital wards into the community end up waiting in hospital for placement, taking up a bed with a level of care that exceeds their requirements.

Further adding to the access block was the process of transferring patients from other hospitals, particularly rural and regional hospitals.  Even though they had been seen by a doctor and assessed as needing transfer, they still had to come through the emergency department rather than going straight to the relevant ward ([117]).  Adding to the exit block was the fact that hospitals operated with fewer staff resources after regular business hours and over the weekends delaying the discharge of patients who no longer require hospital care ([118]).

If the problem can’t be solved, it needs to be made safer

The problem is that hospital overcrowding leads to risk to patient well-being ([122]; [148]). If ramping cannot be solved – it is a problem occurring across all Australian jurisdictions and across the world – then it needs to be made safer.  As His Honour asked (at [150]):

…if ramping is a daily occurrence and addressing the root cause is an enormous issue which will take many years and enormous resources and might actually be impossible, then why would better ways of dealing with the consequences not be a worthwhile exercise?

His Honour was mindful of the argument that making ramping safer may remove the incentive to find a solution to ramping (and see Paramedics as an extra set of hands in ED (June 30, 2024)) but, he said (at [151]):

There is an irrationality about declaring ramping unacceptable, and because of that stance, declining to deal with it directly to make it a less dangerous situation. In this situation, it would be an error to only focus on the enormous task of preventing it happening in the first place. It results in a situation where those patients who face being ramped are in a worse situation than they could have been because those involved are dedicated to preventing ramping, not making it a less dangerous situation when it does happen. This approach completely overlooks the overall goal of the Emergency Department and indeed hospitals and the entire healthcare system; namely to take care of people in the safest way possible in the circumstances in which they present.

And (at [180]):

While the idea of ending ramping is an admirable goal, it cannot be the only solution pursued. To do so creates a situation which continues to put the lives of those that endure the wait on the ramp at risk. While South Australia is a leader in many fields, it seems unlikely to me that we will be the first jurisdiction in the world to put an end to entrenched ramping once and for all. Once this is recognised, superficial complaints about the use of ‘band aid measures’ fall away and the focus on safety nets seem more desirable… safety issues with ramping can be addressed by accepting that ramping is inevitable, without endorsing ramping as acceptable.

Recommendations

His Honour made a number of recommendations. I deal with them in terms of my perception of their interest to readers of this blog rather than in numerical order.

Recommendation 1: A public declaration

The first (at [203]) was

That the South Australian Government formally acknowledge that ramping is a reality that all modern healthcare systems encounter. While efforts to reduce the levels of ramping remain extremely important, efforts must also be made to make the process of ramping safer for those patients who will inevitably experience it.

This recommendation was opposed by the AEA (Ambulance Employees Association). His Honour’s view was that the AEA’s opposition ‘ignores the effect of later recommendations and disregards my reasoning that an entirely new way of thinking needs to be adopted throughout all levels of health care’.  He also noted that the recommendation was opposed by the State of South Australia.  At [205] his honour said:

 I have taken into account the opposition to this recommendation. I still consider that a public statement is the necessary first step to moving beyond a paradigm where so much effort and energy is wasted on discussing ramping figures instead of actually focusing on improvements to the ramping process. It would have the effect of readjusting clinicians’ views about ramping and ensuring their ‘buy-in’ on improvements. It would quell public disquiet about the phenomenon of ramping. I consider that in all of the circumstances of this Inquest, this recommendation is not only appropriate but is critically important.

Recommendation 4: Structured handover

The coroner heard evidence about oral handovers and how easy it was for relevant information not to be passed on, not recorded or its significance missed.  Even with digital patient records there is still a need for an oral handover ([243]).  Structured handovers ‘facilitate the handing over of a complex set of information in a short space of time without missing important topics’ ([244]).

Recommendation 4 ([248]) is ‘A statewide policy should be introduced mandating the use of a structured oral handover between paramedics and triage nurses.’

Recommendation 5: Let paramedics know the patient’s triage category

So that paramedics have an idea of how long they may wait, can communicate effectively with their patients it is recommended that triage nurses ‘… advise paramedics of the triage Category assigned to each patient who is not immediately brought into the Emergency Department’ ([251]).  That would also allow paramedics to consider, if they think the triage category is too low. That may identify whether some information may have been missed or misunderstood in the handover. It would also allow them to make their own assessment about whether a change in the patient’s condition now means the triage category should be changed and bring those matters to the attention of the triage nurse.

Recommendation 6: Taking blood from patients on the ramp

Recommendation 6 (at [252]) is:

That a trial be undertaken of blood samples being taken from patients waiting for emergency treatment in metropolitan hospitals following triage who are anticipated to wait on the ramp beyond their ATS [Australian Triage System] target timeframe, with the usual processes applied for the review of results to detect and raise alarm about results which indicate that the patient is at imminent risk of death…

This recommendation came about because in the case of Mr Jessett’s death, he was suffering from undetected ketoacidosis.  If that had been detected it may have been treated and may have avoided the cardiac arrythmias that ultimately led to his death ([88]). A ‘a simple blood test’ could have been ‘used to detect a serious health issue invisible to observers’ ([90]). 

There were objections to this proposal. One was that ‘comforting results meaning a patient is left on the ramp longer’ ([160]).  His honour said that could be managed if blood results are not used to make triage decisions unless the results are flagged (as they already are) as highly abnormal or dangerous. ‘This is actually a simpler model of implementation because it does not require anyone to be assigned to reviewing ramped patients’ blood samples. Instead, it relies on the process already in place where highly abnormal results are flagged by the pathology unit’ ([160]).

The AEA was concerned that blood results may mean patients in the waiting room are treated ahead of patients ‘on the ramp’ ([162]). His honour gave that argument short shrift (at [163]):

… [This] concern has a fundamental flaw. [It] …  amounts to a complaint that a patient who is sicker will be treated before a patient who is less sick. While SA Health policies require ambulance patients to be prioritised over waiting room patients, this is always subject to both patients being of equal clinical risk… [The AEA’s] … concern was based solely on the industrial situation of paramedics … It has no regard to clinical care required or the welfare of the individual patient that paramedics have in their care weighed up against the welfare of the patient who drove themselves to hospital. Dr Wright said that even if a few patients ended up waiting longer because of their comforting results, but one patient who cannot wait for hours is discovered, then the greater good is served.

Recommendations 7 and 8: Improving conditions on the ramp

The coroner recommended conditions at the ramp be improved to allow greater patient comfort, greater access to patients than is available in an ambulance and systems, such as alarms, to alert staff in the ED if a patient’s condition deteriorates. The coroner recommended that there is a policy to require paramedics to take regular observations with specific action required by paramedics and hospital staff depending on those results (see recommendation 7, [260]).  It was also recommended that ‘ramping’ (ie leaving patients in the care of paramedics) be transferred to better facilities. At [285] Coroner White recommended:

An ambulance waiting area should be constructed adjacent to, but not within, the Emergency Department of each metropolitan hospital which has experienced significant periods of ramping (i.e.,in excess of 300 hours) in the majority of months over three years. These areas should be fitted out with appropriate equipment and supplies familiar to paramedics, to allow for patients who are unable to be immediately admitted to the Emergency Department to wait in the care of paramedics, ambulance officers or nurses outside of the ambulance. These areas should be fitted with appropriate emergency buttons. Policies should prevent the use of this space by the hospital, other than for visualisation and other triage processes by triage nurses, intake blood samples and sudden resuscitation-level events.

Recommendation 10: Duty of care

The coroner explored the legal question of ‘who is responsible for the care of patients on the ramp’? ([301]).  He said (at [302]):

Some witnesses held the view that the hospital only took responsibility for patients once they were admitted. Some witnesses suggested that there might be two shared legal responsibilities. Some suggested that responsibility for patients is split, with each group (paramedics and hospital staff) being required to do their job to the best of their ability.

I would think I sit in that third group (see Ambulance ramping and responsibility for patient care (December 4, 2024); and I note that one of my co-authors of the article referred to in that post was Professor Anne-Maree Kelly who in turn was an expert adviser to the coroner; see also Advising patients who want to leave a hospital emergency department – UK and Australia (October 16, 2018); Treating patients whilst ambulances are ramped (December 28, 2018) and Duties owed to patients in ED (July 17, 2023)).  At [305] Coroner White said:

In my view, the law in the United Kingdom is clear and compelling. There are no clear reasons why it would not be followed in Australia if tested; the hospital has responsibility for patients who present seeking assistance from the point at which the hospital becomes aware of them.

The coroner noted that SA Health had introduced a policy to confirm that hospitals had responsibilities for patients on the ramp ([311]) but this had been subject to critical media analysis, even though it simply restated, rather than changed the law ([312] and see, for example 9 News ‘South Australian opposition under fire for ‘dump and run’ ramping claim’ (January 17, 2025; which seems to be the only story not behind a paywall).  His Honour recommended (Recommendation 10, at [316]):

That a statewide policy be implemented that makes clear that the principal duty of care for a patient who has arrived at hospital lies with that hospital, even if the patient is not admitted to the hospital but is ramped in the care of paramedics.

I’m not sure what His Honour means by the ‘principal duty of care’.  That the hospital owes a duty of care to those patients is correct. But that doesn’t mean that paramedics don’t also owe a duty of care. For example the hospital has to recognise that it has a duty to those patients so would want to have a system to ensure that if a patient ‘crashes’ whilst on the ramp (as happened in Mr Skeffington’s case) or there are concerns that the patient’s condition may not have been properly understood (as happened in Ms Panella’s case) there are systems in place to allow this to be raised. And that hospitals are constantly reviewing patients on the ramp to make sure their triage assessment is correct, and they are not ‘forgotten’.  But equally paramedics have to have a duty to keep assessing their patient, providing care and raising their concerns.  The hospital can only know what it knows and can or should be able to rely on paramedics, as health care professionals to also provide care to the patient. It follows that I don’t disagree with the coroner’s recommendation, but I’m not sure what ‘principal’ means in this context.

Recommendations 11 and 12: Silo thinking

Silo thinking ‘… is, effectively, the disregard of issues in areas of the health system other than the area in which one directly works’ ([318]).  The coroner recommended that everyone in the health system had to consider the impact of their actions on the system. ED staff needed to understand what the outstanding ambulance demand was so they could take steps to release ambulances when it was know there were cases waiting.  Ward staff have to be informed about the pressures on the ED so they can make decisions about discharging patients, perhaps bringing in teams on the weekend rather than waiting until Monday or allowing wards to take on more patients than they are designed for, so the ED can free beds to receive patients.  To that end the coroner recommended (recommendation 11, [321]) that status boards should be rolled out to show, in real time, the level of demand across the health system eg outstanding ambulance calls, the pressure in the ED, the pressure in the wards etc – so the health system could work together.  He also recommended (recommendation 12, [321]) ‘A statewide policy … to address the principles of admitting patients to wards over census.’

Although not address in this section of the report, I note that the coroner talked about the role of the ambulance service.  The AEA’s response to taking blood samples on the ramp has already been discussed, above.  That may be seen as an example of silo thinking as the AEA was considering the impact on the ambulance service and paramedics, rather than the health system as a whole.  It is, I think worth quoting paragraph 131 in full. His Honour said (emphasis added):

The AEA suggested in its written submissions that paramedics join the ambulance service due to a passion for helping those in need. That appears to me to be well established. The AEA went on to say that the problem of ramping prevents them from doing this. I do not accept that these submissions can be linked to each other. It may be readily accepted that ramping hampers the organisation’s ability to help all the people that seek its help each day. However, the individual clinicians who are treating a patient on the ramp are helping those in need; the patient in their ambulance. These are patients who the individual clinician has determined needs admission to the hospital. The hospital has, for complex reasons, not been able to accept them immediately. The individual clinicians are therefore taking on an important role in monitoring and assisting the ramped patients to get through the wait unharmed. It may be that they reasonably have a desire to drop the patient into the Department and return to the community to be of more assistance to others. Understandably, frustration builds when this cannot occur. However, that is a different concept to asserting that they have been prevented from helping those in need. As I have said, every clinician needs to play their role. In the context of the current state of the health system, including the expansion of the ambulance service, at this time it must be the paramedics who take on a wider role of care than they traditionally have. Submissions from the AEA to the effect that paramedics caring for patients on the ramp are not doing their job are perilous. It is true to say they are prevented from helping more South Australians who need them as the system is designed to achieve. The patient waiting with them is no doubt grateful and comforted that they have an advocate in a high-risk situation as I explain below.

At the risk of putting words into the coroner’s mouth, this seems to me to be an example of silo thinking (and see also Paramedics as an extra set of hands in ED (June 30, 2024)). The AEA are focussed on the issue of ramping only form the point of view of its impact on its members rather than the health system as a whole.

Recommendation 18: Ambulance communicating with patients

There was concern that the information given to triple zero callers may not be sufficiently clear when an ambulance response was delayed. The evidence (at [351]) is that callers are told ‘we are experiencing high demand for emergency services’ and this may not be sufficient to communicate that an ambulance is not coming.  The coroner recommended (at [351]):

The SA Ambulance Service should review the accessibility of its scripting in situations where there will be significant delay in the arrival of an ambulance to ensure that it makes the fact of delay clear and provides examples of alternative options.

Other recommendations:

Recommendation 2: That triage nurses visualise all patients (that is look at them, not just take a hand over from paramedics).  He did not go so far as to recommend how this was to be done, rather ‘The policy should allow for each hospital to decide the manner in which visualisation occurs’ [226].

Recommendation 3: Review staffing arrangements to identify what tasks may be done by administrative staff to reduce distracting triage nurses from their key role [239].

Recommendation 9: ‘A review should be conducted by SA Health into the adequacy of the building and facilities of the Flinders Medical Centre Emergency Department to manage its demand and its expected role within the health system…’ ([297]).

Recommendation 13: ‘A review should be conducted into the best manner of achieving an increase in weekend and overnight discharges across the metropolitan area…’ [324].

Recommendation 14: The coroner noted that Adelaide is served by three independent health networks.  This is a national model, but it was noted that the three Adelaide authorities ‘could fit within the single Western Sydney health network’ ([326]).  There was administrative issues with staff working across the networks and paramedics facing different procedures in the different networks. The coroner recommended (at [332]) that:

A review should be conducted into the LHN structure across metropolitan Adelaide to consider whether there are advantages to incorporating all metropolitan LHNs into a single structure with standardised procedures and a single chain of command and whether that would benefit the healthcare provided and those who provide it.

Recommendation 15: The catchment areas for mental health services do not align with the local health networks.  It was recommended (at [336]) that ‘SA Health should consider the appropriateness of the mental health catchment areas and whether the mental health resourcing within those catchment areas is aligned to the expected demand for those areas…’

Recommendation 16: Transit lounges are areas where patients can wait for transport but out of the active treatment space. The coroner recommended (at [339]) that ‘SA Health should explore the expected benefit to the introduction or expansion of 24-hour transit wards accommodating patients of various levels of mobility at the major metropolitan hospitals.’

Recommendation 17: Adverse incident reviews are held but to ensure that they are an independent review, clinicians involved in the actual case are not involved in the review. But in some cases, including at least two of the deaths being investigated by the coroner, there were errors in the review that could have been corrected by the treating practitioners. The coroner recommended (at [350]) that:

SA Health should amend the Clinical Incident Management Policy to include a requirement that clinicians directly involved in providing care are offered the opportunity of providing information to the reviewers on a no-fault basis and including a process for those involved to be notified of the outcome if they wish.

What about the nurses?

The coroner said (at [355]):

Obviously enough, many of the recommendations that have been suggested directly relate to the work of nurses. Counsel Assisting made contact with the Nursing & Midwifery Federation of South Australia in order to encourage their participation, to any degree, in the Inquest. The Federation did not cooperate in any way. It is unfortunate that they did not wish to have any input into an Inquest which was exploring their working conditions and that the Court has not had the benefit of their advice in respect of proposed recommendations. It would be most unfortunate if they were to seek to oppose any recommendations after they have been made. I note now with frustration and disappointment, to say the least, that the Federation has chosen to make public statements on important issues about ramping, both internal and external, and its effect on their members. I cannot now consider nor act on their reported issues revealed publicly on 16 and 17 July 2025.

Conclusion

In simple terms the coroner recognised that ambulance ramping is a problem caused by significant issues across the health sector.  There is no ‘easy fix’ such as simply making hospitals bigger. The problem is an international issue and South Australia is unlikely to solve the problem in the near future. The role of the health service is to provide patient care in the circumstances in which the patient finds themselves and that will include waiting for access to the ED, waiting for access to the wards and waiting for discharge.

If ramping cannot be eliminated it can, in the coroner’s mind, be made safer.  Recognising that and taking steps to improve patient outcomes is not to condone ramping. 

The coroner made 18 recommendations that in his view would improve patient outcomes and may prevent circumstances that lead to the three deaths the subject of this inquest.  Whether those recommendations will be implemented and what effect they have remains to be seen.

This blog is a general discussion of legal principles only.  It is not legal advice. Do not rely on the information here to make decisions regarding your legal position or to make decisions that affect your legal rights or responsibilities. For advice on your particular circumstances always consult an admitted legal practitioner in your state or territory.