Coroner lambasts inept triple-0
Stapleton, John. The Australian [Canberra, A.C.T] 08 May 2009: 3.
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Abstract
NSW Deputy Coroner Carl Milovanovich noted that not once did any of the three women from the NSW Ambulance Service who took the dying boy’s repeated calls even ask his name. There was no explanation as to why the last person to speak to him alive, operator Stacey Dickens, put [David Iredale] on hold twice. Ms Dickens admitted to the inquest she did not have her mind on the job.
The coroner said: “I confess that I was astonished that at no time after the death of David Iredale or any time leading up to the commencement of this inquest, did the Ambulance Service of NSW conduct an appropriate review and/or analysis of their performance in the circumstances leading to David’s death.
He said the operators had paid little regard to what David was saying and the “relentless focus of all the call-takers” on establishing an address rather than trying to help someone so obviously lost in the bush was “astonishing”.
Full Text
THE heartless and incompetent conduct of the triple-0 operators who were the last people to speak to 17-year-old David Iredale before he died of dehydration while bushwalking with friends in the Blue Mountains has provoked calls for a comprehensive review of the service.
The elite private school Sydney Grammar, which David attended, also came in for criticism as the findings of the four-week inquest into David’s death were handed down yesterday.
David became separated from his friends while on a trek for the Duke of Edinburgh Awards in 2006.
NSW Deputy Coroner Carl Milovanovich noted that not once did any of the three women from the NSW Ambulance Service who took the dying boy’s repeated calls even ask his name. There was no explanation as to why the last person to speak to him alive, operator Stacey Dickens, put David on hold twice. Ms Dickens admitted to the inquest she did not have her mind on the job.
The coroner said: “I confess that I was astonished that at no time after the death of David Iredale or any time leading up to the commencement of this inquest, did the Ambulance Service of NSW conduct an appropriate review and/or analysis of their performance in the circumstances leading to David’s death.
“It remains astonishing that a person can ring triple-0 ambulance on five occasions and, there being no satisfactory outcome, that some form of review would not be undertaken.”
NSW Health Minister John Della Bosca said the Government would accept all the recommendations of the inquest and establish a working party to address deficiencies in the emergency call service.
Mr Milovanovich recommended call-takers be trained to show empathy to distressed callers and that a multi-agency working party review the operation and management of triple-0 emergency call centres. The working conditions of operators, including 12-hour shifts with minimal breaks, should also be reviewed, as should their lack of paramedic training.
The inadequate technology being used by emergency services was also exposed by the inquest. Mr Milovanovich said it took four days for the Ambulance Service to locate and download David’s calls and copy them to a CD.
Police then had to send a car from the Blue Mountains to collect the data. The possibility of transferring triple-0 voice grabs via email to search-and-rescue workers with local knowledge should be examined.
He has also recommended a review of the limitations of the existing software and database system, including the inability of the triple-0 computer system to recognise repeat incoming calls, such as from David.
He said the operators had paid little regard to what David was saying and the “relentless focus of all the call-takers” on establishing an address rather than trying to help someone so obviously lost in the bush was “astonishing”.
David’s parents, Stephen and Mary Anne Iredale, left the court while the coroner read on to the record the shocking details of the operators’ performance.
The coroner appeared emotional as he read his findings, and said the case pulled at the heartstrings.
Addressing the family at the conclusion of his findings, he said he had the greatest admiration for them. “You have displayed poise, dignity and composure in the face of unimaginable loss,” he said.
“I hope in some small way this inquest recognises the many achievements of David’s young life. I hope that his death was not in vain and that changes will be made to avoid another family going through what you have gone through.”
Afterwards, on the steps of the court, Dr Iredale thanked the coroner and said the family appreciated the apologies from the Ambulance Service and Sydney Grammar. “We hope that risks of this sort of event happening again will be much lower,” he said.
Credit: John Stapleton