Marina Obbiettivo's family find it difficult to express the devastation caused by her sudden death.
The "lively, bubbly" hairdresser was full of advice and always "called a spade a spade".
She had only recently become "Nonna" to her two baby grandchildren.
"I know it sounds cliche, but [I miss] her food … just that mum stuff," her son Luca Obbiettivo said.
"It was always having someone to talk to and to tell what you're going through.
"I just feel like I don't have that anymore."
Neither Luca, 33, nor his sister Alessia Masson, 34, can talk about their mother without tears.
Only six months on from her death, their grief sits on the surface.
"I often think about what she's missing out on, or what my son is missing out on," Ms Masson said.
"She would share my joy and my pain. And I feel alone even though I have other people around me because it's just a different relationship that you have with your mum."
Marina Obbiettivo died from a heart attack in August, aged 60.
The ambulance should have arrived at her Myrtle Bank home in Adelaide's east within 16 minutes.
But it took 30 minutes — too long to save her life.
The family said they were later told the death could have been avoided with more timely treatment.
An SA Ambulance Service (SAAS) spokesperson said it had "offered condolences" and was "deeply sorry for [the family's] loss".
"Many factors influence SAAS's response to a patient with each case unique and influenced by multiple circumstances," the spokesperson said.
"It is extremely upsetting when SAAS fails to meet community expectations."
A long-term issue with present-day consequences
Ambulance delays, ramping, and hospital overcrowding are connected and complex issues.
Ramping describes the practice of intentionally leaving patients waiting in ambulances at hospitals, under the care of paramedics, when there is not enough space inside the hospital.
It has received particular attention in South Australia in recent years, but it is far from a new issue.
Ramping became a common occurrence at Flinders Medical Centre about a decade ago, and later started at the former Royal Adelaide and Queen Elizabeth hospitals.
Major changes in the system — including the move to the new Royal Adelaide Hospital in 2017 — have not come close to fixing the problem.
Michael Edmonds, from the Australasian College for Emergency Medicine, said the issue had been getting progressively worse over the past decade.
"A day where we don't ramp is odd," he said.
"This has been going on for longer than this government and governments before. It's been tracking this way for many years.
"I don't think anyone can kind of point the finger at anyone solely because everyone has contributed to this over the years to have it heading this way."
A problem getting worse
Ramping levels fluctuate month to month, but the data shows the problem has been getting steadily worse.
In February 2018, ambulance crews lost 653 hours waiting to offload patients.
In October last year, ramping peaked at 2,868 hours, but that was back down to 1,522 hours by last month.
Dr Edmonds said while the system was not currently experiencing its "worst day or worst week", the "goalposts" had changed in emergency medicine.
"Our acceptance of what's normal has really shifted," he said.
"Ramping is a last resort, risk-mitigation strategy when it's not safe inside the emergency department because it's so full.
"People with really time-critical requirements, they come in no matter what and they get their treatment straight away. We make it work.
"[But] each year [ramping] is getting worse and [it's] not sustainable.
As ramping has increased, ambulance response times have been getting longer in South Australia.
According to the most recent data from the Productivity Commission, most emergency cases in South Australia were responded to within 22.6 minutes in the 2019-20 year.
In 2020-21, that increased to 32.8 minutes.
No one cause, no quick fix
"Access block" — or "bed block" — is most often cited as the primary cause of ramping.
"It is people not being able to get into the hospital, and a big part of that is people not being able to leave the hospital at the other end of their journey in the health system," Dr Edmonds said.
"Really ramping is the end symptom, the visible point."
Dr Edmonds said mental health patients and patients who could be cared for in aged or disability-support settings often struggled to move through the system efficiently due to a lack of other services, causing congestion.
"If we have this group of patients who don't have a discharge option and they take up an acute hospital bed, then we don't have an acute hospital bed for those coming into the hospital, so they sit in the emergency room and that becomes overcrowded," he said.
"That means there's no beds available in the emergency department, and then newly arriving patients sit in the ambulance and wait."
Griffith University's academic lead in paramedic education, Mal Boyle, said more doctors, nurses, hospital beds, and ambulance vehicles were often sold as a solution.
But he said not one of those was guaranteed to alleviate ramping without significant investment in other areas such as the aged care sector and community-based health services.
"It's got to be, I think, a bipartisan discussion and it's got to be an issue that all governments look at," he said.
"We've got an ageing population and people are going to live longer … and I think they have to take a long-term view and start looking 10, 20 or 30 years down the track."
Dr Boyle said South Australia was not alone in confronting such issues.
"It's something that's been around for a long time," he said.
"Certainly, [it's been happening] in Victoria, New South Wales and in Queensland, and even Western Australia is having issues with ramping even without having a lot of COVID cases.
"I think [political leaders] are often looking at big bang for buck … but I don't think they're really looking at all the avenues where they could make a difference."
Dr Boyle said the matter was further complicated by the split in responsibilities between the states and Commonwealth — the states with hospitals, the Commonwealth with aged care and disability services.
Can it be fixed?
In the lead-up to the March 19 election, both South Australia's major parties have outlined big spending — either underway or pledged — and have promised to alleviate ambulance ramping.
Dr Edmonds said he believed ramping could be "fixed with significant investment" along with a system-wide rethink of public health — across hospitals, community care, aged care, disability, and mental health.
"I have to have hope that we can do better and we can improve," he said.
"I don't think we should resign ourselves to this being the health system going forward."
Luca Obbiettivo and Alessia Masson are hopeful too — but deeply disappointed and angry over their mother's death.
"You think it (ramping) won't affect you, but it could," Ms Masson said.
"This is literally life and death.
"If I'm being honest, I didn't know about ramping [before] even though it was all over the news.
"To the people that are affected, it completely turns their life upside down.
"I'm not the person I was before [my mother died] and I can never get that person back … ever again.
"It's heartbreaking to know that other families will go through what we've been going through."
