The Ambulance Employees Union revealed on January 4 that a Triple Zero call was made on December 27 for the man, who had abdominal pain and was vomiting.

The Hectorville man lived in a disability care facility and was assessed as requiring an ambulance response within 60 minutes. When his condition deteriorated after hours waiting for help, his case was lifted to priority one but he died before paramedics arrived.

Premier Peter Malinauskas, whose main platform for the 2022 state election was to ‘fix ramping’, said the man’s family had a right to be angry but dismissed calls to sack Health Minister Chris Picton.

However, the government ordered a review into the incident, to be undertaken by SA Chief Medical Officer Dr Michael Cusack, SAAS Chief Medical Adviser Dr Amy Kier and SAAS Operations Manager Clinical Improvement Cathy Wright.

Their Response Delay Review, released today, said that ambulances were forced to wait outside overcrowded emergency departments for a total of 416 hours over a 48-hour period around the time of the man’s call, which “significantly reduced SAAS’s capacity to respond to all events with the greatest impact on low acuity cases”.

“This is the major contributing factor to the delay,” the report reads.

Other findings included that “SAAS was able to manage the increase in Triple Zero call volume during most hours, however Triple Zero volume and response delays were exceptionally high creating delays in the call back process”.

It was also found that the risk profile for the Hectorville man was “underappreciated and was not considered in determining the appropriate priority or the potential escalation of care given the system pressures on the day”.

The recommendations include SAAS working closely with local health networks to reduce ramping, the Service “needs to identify cases of greatest risk and implement procedural guidance to help prioritise call backs during periods of high demand”.

It also recommended that SAAS “refine current operational procedures, reporting, and dispatch with the intention of optimising all components of internal ambulance capacity, especially to delayed cases”.

A procedural review to “better assess response to care of vulnerable patients” was also recommended, as was a need to “refine the call back procedures” and “consolidate the workflows of clinicians”.

It was also recommended that the video-telehealth pilot planned by SAAS be “prioritised for commencement”.

The findings and recommendations can be read here in full.

Health Minister Chris Picton said SAAS would “immediately get to work on implementing [the findings] to improve the system”.

“This death was a tragedy that shocked the entire state. We acknowledge the immense pain caused to the family and we extend our deepest condolences,” Picton said.

“We are committed to doing absolutely everything we can to improve ambulance response times and reduce ramping to help prevent such future tragedies.

“Our ambos work tirelessly for the South Australian community, often in very difficult circumstances, and I thank the reviewers for their recommendations that will help ensure our patients get the most appropriate care when calling an ambulance.”

SAAS CEO Rob Elliott said he was “dedicated to making any improvements that we can make”.

“While this review focuses internally on SAAS, and the improvements we can make ourselves, the need to ensure ambulances are available to the community is paramount and must not be overlooked,” Elliott said.

“These recommendations will improve the efficiency and effectiveness of our internal safety nets for delayed responses when ambulances are not available, and I am committed to supporting these changes to improve patient safety and help prevent future tragedies.”

At a January press conference, the man’s family said he was failed by the state’s health system.

“He was an eternal child that was extremely… sick throughout his life,” his uncle then said.

“But he needed help, and he didn’t receive the help he richly deserved. He didn’t have a voice. He couldn’t tell anybody ‘please get the ambulance to me, I need it desperately’.

“He couldn’t talk, so he just had to suffer while calls were made, and he just didn’t make it… when the ambulance arrived it was just too late for him.

“He was a great kid in his way, but he was also a man who should have been treated with more respect and dignity.”

Speaking on behalf of Eddie’s family today, opposition leader David Speirs said the situation had “created an incredible level of anxiety and pain”.

“The family are comforted that these recommendations have been made, and while they wish that it hadn’t got to this stage…they are grateful that this review has at least happened,” he said.

“They’re heartbroken of course, but let’s hope that these recommendations can be fulfilled and Eddie’s death won’t be in vain.”