A man waited more than two hours for an ambulance before his death on a night of significant ramping and unusually high call volumes, a coronial inquest has heard.
The inquest — being heard by Deputy Coroner Ian White — is examining whether the delay in ambulance crews arriving contributed to the death of Craig Malcolm Files in Norwood, in Adelaide's east, on the morning of January 30, 2019.
Mr Files was suffering from multiple medical conditions, including alcoholic liver disease, at the time he had a fall and called for medical help.
The first triple-0 call was made on his behalf shortly before 12:30am, but an ambulance did not arrive at the Norwood address until close to 2:30am.
Paramedics attempted to resuscitate the 54-year-old, who had gone into cardiac arrest, but he died at the scene.
He had been listed as a "priority three" case, which carried a key performance indicator (KPI) of a 30-minute response time.
SA Ambulance Service (SAAS) operations manager Richard Larson told the inquest there had been a combination of events "over the flow of the evening that contributed to the delay".
He said those events included periods of unusually high triple-0 call volumes, and significant ramping at the state's public hospitals.
Mr Larson told the inquest the volume of calls had dropped below "predicted demand" around midnight on January 30, but that the ambulance service was still "playing catch up" on other jobs from earlier in the evening when Mr Files' case came through.
"A large number [of calls] were being held over ... or banked ... waiting for a crew to be available to respond," he said.
"Ideally there shouldn't be any being held.
"They should be tasked at the time they're coming in."
Mr Larson told the inquest that at the time of the first call regarding Mr Files, 19 ambulance crews were sitting ramped at metropolitan hospitals.
"[There were] three crews that night where they were able to find a record of a break being taken," he said.
The inquest heard SAAS operators did not perform a "call-back" for Mr Files' case despite the significant delay, possibly due to "confusion" following a second call made on his behalf at around 1:30am.
It heard the call-back system at the time of the incident created a list of cases in reverse-chronological order, meaning the oldest cases were continually pushed further down the list.
That system has since been switched to show the "oldest" cases requiring a call-back first in the list.
Ramping worse, union says
The inquest into Mr Files' death has been joined with the inquest into the death of Virginia Anne Weekes, who died after waiting for an ambulance in April last year.
Outside the inquest, Ambulance Employees Association state secretary Phil Palmer said the situation had "deteriorated" since 2019, and that "ramping was worse".
"I haven't heard anything that surprised me today," he said.
"People are dying waiting for ambulances ... and those cases will quite likely end up in the Coroner's Court [too].
"This won't be the last of the cases investigated."
