The State Government has accepted the recommendations handed down by the Deputy State Coroner following the investigation into the deaths of Anna Vincenza Panella, Bernard Anthony Skeffington and Graham Henry Jessett, between April 2019 and March 2022.
The Coroner made 18 recommendations aimed at improving patient safety and system flow, focusing on ambulance ramping, triage procedures, and hospital capacity.
SA Health is progressing implementation of all recommendations, with immediate priorities including:
- improving patient monitoring and systemwide demand oversight
- establishing clearer accountability and reporting frameworks
- reviewing existing clinical protocols and escalation pathways
- assessing ambulance offload models, including infrastructure requirements and what is physically feasible at metropolitan hospitals
- exploring opportunities to increase weekend and overnight discharges across metropolitan hospitals
The Coroner has described SA Health's strategies to respond to ramping as "extremely comprehensive and well thought through" and says they represent "an excellent use of public funds".
The Coroner also acknowledged the significant improvements in ambulance response times, noting that wait times for an ambulance had been "drastically reduced" and that "people in the community who need the care of paramedics receive it quickly".
SA Health has established an oversight committee which meets monthly to oversee the timely implementation of each recommendation.
Two key recommendations regarding clinical incident management and hospital duty of care have already been endorsed as complete.
A six-month pilot of pre-hospital blood collection commenced at the Royal Adelaide Hospital and the Queen Elizabeth Hospital last month, which allows SA Ambulance officers to collect blood, either at the scene or if transfer of care is delayed at the hospital.
This will enable earlier detections of clinical risk and allow timelier decision making about the patient's progression of care.
It follows the Malinauskas Labor Government's more than $9 billion dollar investment in the health sector over the past four years, to ease pressure on hospitals.
This includes the addition of 700 extra beds across the health system, with a commitment for 300 more.
More than 4,000 additional health workers have been recruited, including 2,091 more nurses and midwives, 933 doctors, 374 ambulance officers and 603 allied health professionals.
The State Government has also invested heavily in bolstering the South Australian Ambulance Service, with a new $134 million dollar headquarters and state health coordination centre and 24 brand-new, upgraded or completely rebuilt ambulance stations in addition to the 374 extra staff.
It comes as latest ambulance ramping data shows signs of improvement, with 3,958 hours in May 2026, down 831 hours, or 17 per cent, on last May.
The biggest improvement was seen at the Central Adelaide Local Health Network, where ramping reduced by 47 per cent year on year, from 2,518 in May 2025 to 1,339 hours in May 2026.
Year to date we have seen a 5.7 per cent reduction in overall ramping hours lost compared with the same period last year, resulting in 1,137 fewer hours lost.
Despite continued growth in demand, ambulances are reaching more urgent patients within target timeframes.
In May 2026, ambulances reached 73.2 per cent of Priority 1 cases in the target timeframe of 8 minutes, compared to 72.3 per cent in May 2025.
Ambulances reached 67.1 per cent of Priority 2 cases in the target 16-minute timeframe in May 2026, compared to 60.0 per cent in May 2025.
There are currently 426 elderly South Australians stuck in metro hospitals and other SA Health sites medically ready for discharge, but waiting for a Federal Government aged care bed.
This highlights the importance of targeted investments such as College Grove, where 20 beds are already online and a further 30 beds are on the way, helping longer-stay older patients move out of public hospitals and into more appropriate care and reducing pressure on emergency departments.
As put by Blair Boyer
First and foremost, my thoughts are with the families who have lost loved ones at the centre of this inquest.
The Coroner's findings are a sobering reminder of the pressure facing the health system and the importance of ensuring patients receive timely and appropriate care at every stage of their treatment.
The Government accepts the Coroner's recommendations and is committed to implementing changes to improve patient safety.
We are committed to continuing to invest in reforms that improve safety, capacity and care for South Australians.
In April, we launched our Winter Plan to help prepare for and manage increased demand during this period. This includes opening more bed capacity, improving patient flow and making sure people can get the care they need, when they need it.
As put by SA Health Chief Executive, Dr Robyn Lawrence
I acknowledge the grief and distress experienced by the families involved and extend my sincere condolences for their loss.
We accept the Coroner's recommendations and are committed to implementing the changes necessary to improve patient outcomes, and reduce the risk of similar incidents occurring in the future.
This includes reforms to strengthen escalation processes, improve clinical oversight, support earlier identification of patient deterioration, and reduce pressure across emergency departments and hospitals.
The introduction of pre-hospital blood testing, increasing weekend and overnight discharges, and assessment of infrastructure and demand management practices are practical measures aimed at improving patient flow and ensuring patients continue to receive timely, safe, and appropriate care, even during periods of high demand.
While the Coroner acknowledged the huge amount of work and progress already made to tackle ramping, we know there is more work to do. We are committed to working closely with clinicians, ambulance service and local health networks to deliver meaningful and lasting improvements across the health system.
