Inquest into the death of RD

Case Number: 2019/289857

Date of Findings: 4 April 2025

Magistrate: Coroner, Sally McLaughlin

CORONIAL LAW – Group A Streptococcus pneumonia with sepsis – NSW Ambulance protocols for transportation when vital signs outside the reference range/outside the flags – point of care recognition of vital signs outside of reference range

Responses

Recommendations

To NSW Ambulance

1. That NSW Ambulance consider developing a feature in current or future NSW Ambulance systems that are used at a point of care, whereby a visual prompt or alert is activated where a patient’s vital signs are outside normal limits and/or requires transport to hospital, in accordance with relevant protocols or clinical practice guidelines.