On the Facebook version of this page I posted links to news stories relating to the death of Stacy Yean.

For this blog I have gone to the findings of the Coroner, Philip Byrne.

What happened?

Ms Yean was 23 years old.  She became very ill on 5 January 2016.  After 2 hours, the family called the local hospital for advice and was told to contact her doctor.   A call was made to the doctor but the doctor was unavailable and the locum service did not provide house calls in that area.

At 3.15pm a call was made to triple zero.  The initial call taker triaged the call as non-life threatening and it was transferred to Ambulance Victoria’s referral service.  A paramedic took the call and determined that an ambulance was not required but the family were invited to call triple zero again should circumstances change.

At 4.30pm another triple zero call was made and an ambulance was dispatched.   The ambulance was staffed by an experienced paramedic educator and a graduate paramedic who had been ‘on the road’ for only 2 weeks.   The paramedics took two sets of observations, 10 minutes apart, and concluded that Ms Yean ‘may have a “gastric bug” and [her] presentation did not mandate transport to hospital’.   They offered to take her to hospital but did advise that the hospital was busy and she was likely to face a long delay in being seen.   In light of the advice, Ms Yean declined the offer of transport to hospital.

Ms Yean came out of her bedroom at 11pm and spent some time with her father before returning to bed.  She appeared to be asleep at 1am.  At 11am she was found deceased in her bed.  An autopsy, including toxicology, biochemical and microbiological analysis, failed to identify the cause of death.

In the circumstances the Coroner held a full inquest with oral evidence from those involved.

Matters in contention

One can only imagine the heartbreak that Ms Yean’s family must have felt.  They called triple zero, their daughter was not taken to hospital, and she died.

In a poignant statement, Mr James Yean said:

“I am sure that if she was taken to hospital on the 5th of January 2016, my daughter Stacey would still be alive”.

In a letter to the Court dated 11 May 2016 Mrs Adrienne Yean wrote:

“If the right call had been made Stacey would still be with us today or at the very least she would have passed in a hospital setting with people who could have tried to save her life, not alone in her room.”

The fundamental thrust of the family’s position is that claimed deficiencies in the management of Ms Yean on the afternoon of 5 January 2016 were causal factors in her death.

In light of the family’s concerns the coroner undertook a detailed investigation into the response by Ambulance Victoria.

The 3.15pm triple zero call

This call was referred to the referral service and no ambulance was sent.   In a review of the call, Ambulance Victoria identified that various questions, required by the triage procedures, were not asked.  The coroner considered the impact of that failure but concluded that, even if those questions had been asked, the outcome would have been the same.  The failure to send an ambulance at 3.15pm did not contribute to Ms Yean’s death because her ‘condition did not deteriorate or alter significantly’ between that time and 4.30pm when the second triple zero call was made and an ambulance was despatched.

The assessment by paramedics at 4.30pm

There was an issue as to whether or not the paramedics refused to transport Ms Yean to hospital.  After some evidence it was conceded that they paramedics had offered to transport her but had warned Ms Yean that there was likely to be a significant delay. According to the family, it was said ‘that she might have to wait in the Emergency Department for 5-6 hours with a bucket between her legs.’  The paramedics confirmed that they did advise there would be a wait, but denied that they specified a particular time.

Ms Yean’s father said that he offered to drive his daughter to hospital but she declined because of the advice received from the paramedics, that there would be a long delay.   Counsel for the family asked the coroner to find that the advice, and consequent decision not to go to hospital, contributed to Ms Yean’s death.  The coroner did not make that finding.  He said:

While the prospect of a significant wait in the Emergency Department was no doubt one of the factors, perhaps even the main reason Ms Yean declined the offer of transportation, that cannot reasonably be seen as causal or contributing factors in her subsequent death; it was merely stating a likely fact.

He went on (emphasis in original):

I find the interpretation put on the issue of transportation by both parties, AV and the family interesting. Ms Handley [one of the paramedics] states Ms Yean “refused” the offer of transportation. I would have thought a more appropriate interpretation would be “declined” rather than “refused”.  The family maintain Ms Yean was “talked out” of going to hospital; both interpretations are, in my view, strained.

I do not consider it unreasonable for a paramedic to advise a patient there may well be a significant delay in being seen at an Emergency Department, particularly if that paramedic has observed ambulances “ramped” earlier in the day.  The decision taken, while no doubt influenced by the prospect of a significant delay, ultimately was taken by Ms Yean, I do not accept she was refused transport to hospital.

The bottom line is, the offer of transportation was made, but declined.  Of course no one could have predicted the tragic event which unfolded sometime overnight, at a time I am unable to determine.

Professor Stephen Bernard, Senior Medical Advisor to Ambulance Victoria gave evidence.  He confirmed that the actions by the paramedics were in accord with then clinical practice guidelines.  The coroner said (emphasis in original):

Bearing in mind that the paramedics are the professionals, I suggest that in the final analysis their assessment of the patient, following clinical guidelines, is the appropriate basis upon which a decision is taken to transport, or not.

Having carefully reviewed the evidence … I have concluded that [the paramedics’] … assessment of Ms Yean’s condition was in accordance with AV’s clinical practice guidelines, their performance did not depart from a norm or standard, nor did it fall short of a recognised duty.  Consequently, in my considered view, I conclude the weight of the evidence does not warrant the making of an adverse finding, or indeed comment, against the paramedics or AV.

Finally the family claimed that during an Open Disclosure process, designed to work with the family to explain and explore what had happened, a representative of Ambulance Victoria conceded that Ambulance Victoria had been at fault in the way Ms Yean was treated.   The Coroner observed (emphasis in original) that:

Over the years I have quite often observed a mere apology or expression of sympathy construed as an acknowledgement of fault/culpability when clearly it is not.

I do not accept the contention that … on behalf of AV, admitted a deficiency in performance by AV staff.  I believe any belief to the contrary is likely founded upon a misunderstanding, miscommunication, misinterpretation or a combination of all three, of what Mr … sought to convey.

Commentary

Let me first acknowledge the terrible tragedy in this case.  The family of Ms Yean did all that they could do, they sought medical advice and acted on it.  As a parent one hopes that this will lead to the best outcome but in this case the outcome was as bad as it could be.  One can understand their grief, frustration and loss and belief that someone, Ambulance Victoria paramedics, let them down.

For the paramedics this too must be a tragic case.  They gave their honest advice and opinion and their patient died and they had to spend a year reliving the matter for the coroner.  For one of the paramedics, with only 2 weeks on road experience, this will no doubt be a formative experience in their career.   We can only feel sympathy for them, too.

Elsewhere I have argued that paramedics should not be required to transport everyone – see:

This case highlights the risk of not transporting everyone, but as the Coroner noted:

It is possible perhaps even probable, that Ms Yean, even if transported to hospital, would have been discharged home, probably after the provision of an anti-emetic medication, rather than be admitted.

The coroner was not critical of the decision to advice Ms Yean of the likely delay nor of the decision of Ms Yean to chose not to go to hospital.  Paramedics are professionals and are there to exercise their professional judgment.  They could not have foreseen the consequence in this case.

The tragedy here is that there is no doubt that everyone was trying to do the best that they could for Ms Yean. The family sought medical advice; the advisors gave their honest opinion that her condition did not warrant hospital treatment and that if taken to hospital there would have been significant delays.   Given that, even now it is not known what caused Ms Yean’s death, it can’t be said that any decision was wrong or that transporting her to hospital would have made a difference.