The Northern Territory coroner has found ambulance delays contributed to the deaths of two Darwin patients earlier this year, who waited six and five hours respectively for paramedics to arrive.
Coroner Elisabeth Armitage released her findings today into the deaths of three patients, aged between 75 and 89, who each died in January and February this year after soaring demand for ambulance services meant no clinically appropriate resources were available.
The coroner found that in two of the three cases, a delay in treatment was identified by the forensic pathologist as a factor contributing to the patients' deaths.
St John NT said patients in the territory can expect continued delayed responses due to the service being under-resourced.
On February 7, an 80-year-old man collapsed in the family bathroom but managed to make it to the lounge where he asked his wife to get his medication before she heard him crash to the floor.
On returning to the lounge, the woman found her husband bleeding from the head and in too much pain to be moved safely.
The family called emergency services at 8:12am and spent the next six hours waiting for an ambulance, which took him to Royal Darwin Hospital, where he died later that afternoon.
Judge Armitage found St John was down a crew at the time and "every available emergency unit was already committed to higher-priority cases".
"Accordingly, St John NT advises that the delay was not attributable to an incorrect priority allocation but arose from concurrent higher-acuity demand and the limited availability of appropriate ambulance resources," she wrote.
'Limited ambulance availability' contributed to delay
The following day, nursing home staff found an 89-year-old woman on the floor screaming for help after a fall, and called for an ambulance at 2:06pm, but she remained sitting on the floor waiting until 6:45pm when she was transferred to a wheelchair.
Paramedics finally arrived about 7:08pm to find her "agitated and verbally disturbed", with a CT scan later revealing she had five broken ribs and a collapsed lung.
She died at Royal Darwin Hospital 11 days later.
Judge Armitage said St John had advised several incidents were prioritised over the woman's case, either because they were more serious or the patients were not being monitored by health care professionals.
"St John NT advised that this patient was being monitored by a health care professional with medical observations within normal range and it received no requests for an urgent response," she wrote.
"St John NT advised that the delay in attending the nursing home was due to limited ambulance availability during the relevant period, with multiple crews already committed to other incidents or off-road.
"It was the opinion of the forensic pathologist who carefully reviewed her medical records that the 'long lie' of five hours contributed to her death."
The third patient, a 75-year-old woman, also collapsed at an aged care home in January and later died in hospital after waiting an hour-and-a-half for an ambulance, but the pathologist found the delay did not contribute to her death.
Emergency demand exceeds resources, St John says
In response to a draft of the coroner's findings, St John NT said ambulance demand had increased by 37.7 per cent between 2020 and 2025, and by 61.1 per cent since 2015, substantially exceeding population growth.
The service said such pressure was "routinely evident operationally" and reported to the NT Health Department weekly.
"Following these incidents, the Northern Territory government provided an additional $10 million investment in ambulance services," it said.
"St John NT is working to apply that investment to improve operational resilience and better align available resources with periods of highest demand.
"However, the additional investment does not address the full service-capacity gap identified through current demand and utilisation analysis, particularly in Darwin."
St John NT said it was currently working on a model that would "progressively increase emergency ambulance capacity in Darwin and Alice Springs" but the measures were "not currently commissioned" and remained subject to government agreement and funding.
It said "materially reducing the underlying system risk" would require additional funding and the service would continue to work with the Health Department to address the risk within its current resourcing.
"Where emergency demand exceeds the number of immediately available, clinically appropriate ambulance resources, patients may continue to experience delayed responses despite correct prioritisation and escalation processes."
In a statement, NT Minister for Health Steve Edgington said he passed on his "sincere condolences to the families of these elderly Territorians who passed away".
Mr Edgington cited the $10 million support package for St John as part of the government's action to "help meet increasing ambulance demand".
"The $10m funding boost in the 2026 budget is for an immediate boost in operations, while a five-year funding agreement is finalised," he said.
"St John ambulance will receive $68 million in the budget, which is almost double what the Labor government provided."
