Paramedic's 'flawed understanding' of powers led to delayed entry in death inquest

A paramedic who chose not to force entry to a house, despite being told a man was inside and needed medical attention, had "a flawed understanding" of his powers to enter the property, an inquest finds.

South Australia's State Coroner David Whittle handed down his findings on Monday into the death of 64-year-old David Low, who had heart complications along with a number of health issues including diabetes and morbid obesity, on February 25, 2020.

The inquest, which ran in December 2024, explored the "processes and procedures" when the SA Ambulance Service (SAAS) attended Mr Low's house, "as well as the considerations which led to delayed entry".

Although Mr Whittle determined that Mr Low's death was "unlikely to have been preventable", he handed down eight recommendations — six to South Australia's Minister for Health and Wellbeing and two to the Minister for Police.

In his findings, Mr Whittle said that Mr Low's carer rang SAAS after Mr Low sounded "really distressed and was grunting in pain" during a phone call while at home.

"He apparently dropped the phone and the call abruptly ended," Mr Whittle wrote.

"Notwithstanding the reasonably prompt attendance of a paramedic, entry was not made for quite some time."

The inquest heard evidence from the attending intensive care paramedic Darryl Sparrow, who had 20 years' experience in the ambulance service.

Mr Sparrow had told the inquest that he did not exercise his power to force entry to the premises because he was not convinced Mr Low was inside.

"So, yeah, I don't really want to go in all guns blazing and find he is not here," he had been heard saying on a phone call played to the court.

It also heard that SA Police officers eventually arrived at the scene and that Sergeant Amanda Weaver was "in firm belief that the patient was inside the premises and required assistance".

In his findings, Mr Whittle said that Mr Sparrow later spoke to the Operations Centre and "reported that there was 'a bit of argy bargy here about whether we should be exercising our powers of entry'".

Mr Whittle said that entry was not gained to the house until Mr Low's daughter arrived.

He also said that, upon discovering Mr Low's body, Mr Sparrow doubled down that "we didn't have enough evidence to force entry".

"[Mr Sparrow] said that Mr Low was so heavy that he would not have even started CPR if he had entered," he said.

Mr Whittle said that an expert was able to "surmise", using data from Mr Low's pacemaker, that he died between 4:18pm and 4:39pm "during which time Mr Sparrow was outside Mr Low's house".

He also said that Mr Sparrow "appeared to do everything he could to prove that Mr Low was elsewhere, while the clock ticked away".

Mr Whittle added that Mr Sparrow "appeared to be guarding himself" while giving evidence.

"In my assessment, Mr Sparrow appeared to be a witness who was considering very carefully the consequences of his answers," he said.

However, Mr Whittle said it was "hardly surprising that paramedics like Darryl Sparrow have a flawed understanding of their power of entry".

"Mr Sparrow said he had never read the procedure and that he learnt it through 'osmosis'," he said.

Recommendations to speed up entry

The State Coroner recommended that all ambulances and SPRINT cars, as well as more police patrol cars, be equipped "with devices to assist with forcing entry" to premises.

Among the recommendations to the health minister included an "immunity from liability" for SAAS to ensure no time is lost in emergency situations.

Mr Whittle also noted that SAAS has amended the "Procedure — Forced entry to property by ambulance officers" to refer paramedics to the relevant section in the Health Care Act.

"While the reference is a positive improvement, it still does not quote the terms of the power SAAS members are expected to exercise and thus requires further research to be done by those to whom the procedure applies," he said.

Mr Whittle subsequently recommended that the procedure be rewritten "to align with the legislative power and to give guidance about its application in urgent situations".

He also recommended "that SAAS implement training on section 61 of the Health Care Act in light of the re-written policy".

Mr Whittle also expressed his condolences to Mr Low's family.

"His death was accompanied by particular circumstances of tragedy, in that it is likely that he died within metres of a paramedic trained and able to render potentially life-saving assistance," he said.

"I hope that this situation will not occur again to any other family."

In a statement, the SA government said it would consider the recommendations and extended their condolences to Mr Low's family and friends.

"As the coroner said, the fact that Mr Low’s death was unlikely to be preventable does not diminish the importance of our emergency services understanding and being supported to use the power of authorised entry," a government spokesperson said.

"The SA Ambulance Service has acted ahead of the coroner’s findings being made to increase awareness of when staff are authorised to force entry to premises, with a revised policy provided to all staff and implemented."