A 36-year-old Canberra woman would have been less likely to die had the ACT Ambulance Service responded more effectively to a call for help, a coroner's report has found.
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Rachel Sarah Prime died at Canberra's Calvary Hospital in February 2014 after suffering complications from type 1 diabetes. She was taken to hospital after a 30 minute delay by crews from the ACT Ambulance Service.
In his February 20 report, Coroner Peter Morrison found the call to emergency services had been incorrectly classified to a status lower than the circumstances required, causing the delay in Ms Prime reaching hospital for treatment.
Mr Morrison said the mistake had been "materially influenced by the priority assigned by the ACT Ambulance Service communication clinician" and that Ms Prime's case had warranted higher priority and a faster response time.
"The ACT Ambulance Service communication clinician wrongly assigned a lower level of priority to the case than the circumstances warranted.
"The deceased is likely to have had better prospects of survival were it not for the delay in arriving at hospital," Mr Morrison said.
The events surrounding Ms Prime's death sparked two ACT government reviews, including an immediate case review and a further inquiry conducted six months later. The two reviews resulted in 11 recommendations being presented to the government.
Attorney-General Simon Corbell tabled the coroner's report and the government's response in the ACT Legislative Assembly on Thursday.
The response showed the government has already implemented recommendations around clinician's involvement in emergency calls, new oversight from team leaders and new sub-categories for priority calls.
Two more recommendations from the coroner, including on call backs to people reporting emergencies, and a new queue alert system are currently being implemented.
The Health Services Commissioner is also monitoring the implementation of both sets of report recommendations, Mr Corbell said.
In a statement on Friday, Emergency Services Agency Commissioner Dominic Lane expressed his sympathy to Ms Prime's family.
"We are truly sorry that Ms Prime's unfortunate death has caused much grief and distress to her family and friends," Mr Lane said.
"I commend Ms Prime's family and friends for their patience while we awaited the outcomes of the government's reviews, the Coroner's report and the government's response to that report.
Mr Lane said the agency had accepted all recommendations from both reports, of which 10 have already been implemented. The final recommendation will be considered before the end of the 2015-16 financial year.
"The ESA and ACT Ambulance Service have both learned from these tragic circumstances and implemented changes as a result," Mr Lane said.
"We remain committed to providing the ACT with the highest quality of ambulance services."
