State govt accepts recommendations from ramping inquest
The state government has accepted recommendations to improve ambulance ramping following an inquest into three deaths between 2019 and 2022.
The state government has accepted 18 recommendations handed down by the Deputy Coroner to improve patient safety, with a focus on ambulance ramping, triage procedures, and hospital capacity.
It follows 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 Graham Henry Jessett in March 2022.
Panella died at the Royal Adelaide Hospital as a result of pulmonary thromboembolism – a sudden blockage of a lung artery – due to a left-calf deep vein thrombosis.
Skeffington died at the Royal Adelaide Hospital from aspiration pneumonia secondary to small bowel obstruction, while Jessett died at the Flinders Medical Centre because of ischaemic heart disease with cardiomegaly – an enlarged heart – contributed to by hyperkalaemia.
The inquest findings and recommendations were published on July 31, 2025, outlining suggestions that would assist with the effort to reduce ramping, improve triage procedures and increase hospital capacity.
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The recommendations included an acknowledgement by the state government that ramping is a reality that all modern healthcare systems encounter, a commitment for ambulance waiting areas to be constructed adjacent to emergency departments of each metropolitan hospital, and explore the benefits of 24-hour transit wards.
Health Minister Blair Boyer confirmed today the government would fully accept 17 of the 18 recommendations and accept the remaining recommendation on principle to “improve patient safety”.
The only recommendation not adopted by the government today was the consolidation of Adelaide’s three metropolitan Local Health Networks.
“First and foremost, my thoughts are with the families who have lost loved ones at the centre of this inquest,” Boyer said.
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“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.
“We are committed to continuing to invest in reforms that improve safety, capacity and care for South Australians.”
SA Health is in the stages of implementing these recommendations, with immediate priorities including an improvement on patient monitoring and systemwide demand oversight and exploring opportunities to increase weekend and overnight discharges in metropolitan hospitals.
SA Health has established an oversight committee which meets monthly to oversee the timely implementation of each recommendation.
The Australian Medical Association SA welcomed the government’s decision to adopt the recommendations.
AMA SA president Peter Subramaniam said the commitment to act on the coronial recommendations was a positive step but must also be backed by evidence-based reform.
“The coronial findings confirm what AMA SA has long said: ramping is not an ambulance problem – it’s a whole-of-system problem,” Subramaniam said.
“And it’s not improving at the level South Australians deserve and expect. The latest SA Health figures show 3,958 hours were lost on the ramp in May – roughly on par with the 3,949 hours recorded in April.
“In this week’s budget and beyond, we are calling for targeted investment in community care – general practice, mental healthcare and aged care – to reduce preventable hospitalisations that drive ramping and bed block in the first place.
“We need to treat the cause, not just the queue.”
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