An inquest into three unrelated deaths of South Australians affected by ambulance ramping has started in Adelaide – including one man who waited in an ambulance for five hours.

Deputy State Coroner Ian White is holding an inquest into the deaths of 76-year-old Anna Vincenza Panella in April 2019, 89-year-old Bernard Anthony Skeffington in September 2021 and 64-year-old Graham Henry Jessett in March 2022.

Each of the three people died after waiting on the doorstep of emergency departments at either the Royal Adelaide Hospital (RAH) or Flinders Medical Centre.

Opening the inquest, counsel assisting the coroner Darren Evans told the court that ambulance ramping was the “overlapping issue” of each case.

He said he expected emergency department circumstances and decisions, along with “access block” which occurs when there is an inability to move patients out of the ED and into the hospital to be key issues.

He said the inquest would also consider whether the Australasian Triage Scale – a tool used to determine the maximum waiting time for the medical assessment and treatment of a patient — was working and being properly administered.

‘Seven shots of adrenaline’

Mr Jessett had a “complex medical history” including a previous heart attack, type 1 diabetes, and recent shingles and COVID-19 infections.

His wife called for an ambulance when he experienced chest pain, lethargy, breathing issues and became unresponsive.

Mr Jessett was in an ambulance for five hours before being moved to a hospital bed. (ABC News: Che Chorley)

“Mr Jessett was transferring from an ambulance to a hospital bed about five hours after arriving at hospital,” Mr Evans said.

While being transferred to hospital, he went into cardiac arrest.

Medical staff commenced CPR, administered seven shots of adrenaline, and intubated Mr Jessett, but he was pronounced dead about an hour later.

Ambulances diverted

The court heard Mr Skeffington called for an ambulance in September 2021, suffering from stomach pain and vomiting.

Two ambulances were re-tasked before a third ambulance was dispatched, three hours and 43 minutes after his first request.

The inquest will be heard in the Coroners Court of South Australia.(ABC News: Lincoln Rothall)

Mr Skeffington received care from paramedics while waiting on the ramp at the RAH, where his condition “rapidly deteriorated”.

The triage report from that afternoon noted, “the emergency department is currently overcrowded and unsafe, capacity for clinical assessment and care delivery is compromised as a direct result of this and may affect this patient, hospital executive are aware of the situation.”

One hour and 43 minutes after arriving at hospital, he was admitted to the emergency department in peri-arrest.

His condition deteriorated in hospital and he died four days later, shortly after being transferred to comfort care.

A review found that aspiration pneumonia secondary to a small bowel obstruction was the cause of death.

Mr Evans told the court that Mrs Panella arrived at the RAH via ambulance after experiencing dizziness and a fall.

Her condition worsened outside the hospital and she was taken into resuscitation at the hospital 50 minutes after arriving.

About 10 minutes later she suffered a cardiac arrest and underwent CPR.

She was not able to be revived and was later pronounced dead.

Ramping peak in November

Chart from SA Health shows ramped hours across metropolitan public hospitals from March 2019, to the ramping peak in November 2023. (Supplied: SA Health)

Mr Evans said the number of ramping hours per month across SA Heath peaked in November 2023 at 4,285.

He said while “some waiting was inevitable” it was “unfortunate that we even have a word” for ambulance ramping, which is also known as “delayed transfer of care”.

“It is particularly tragic that inside the hospital there are medical staff with all of the skills, all of the knowledge and the best intentions in the world that sick people just don’t get in to see,” he said.

“Each turned to the health system at their time of most need, each was made to wait on the doorstep of a hospital, the health concerns of each escalated to a point where they lost their lives.”

Mr Evans said he expected the inquest would also hear evidence from SA Health about efforts made to address ramping and whether there had been any improvement.

Multiple witnesses are expected to be called, including paramedics, triage nurses and doctors.

The inquest is expected to continue over the next fortnight.

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