When every second counts, a delay or misstep in emergency response can mean the difference between life and death. Recent inquests in Ireland, Australia, and Northern Ireland have shone a harsh spotlight on the vulnerabilities in emergency care systems, raising pressing questions about training, communication, and systemic obstacles. These stories, while separated by continents, echo a common refrain: families left grieving and officials searching for answers amid tragic outcomes that might have been prevented.
In Adelaide, Australia, the death of 71-year-old Ronald Maine has prompted a searching inquiry into the standards of care at the Helping Hand nursing home in Mawson Lakes. According to ABC News, Maine, who had been diagnosed with frontotemporal dementia five years prior, was known to have a high risk of choking. Despite this, on September 27, 2022, he was found pale, clammy, and with blue fingertips after his morning tea. Staff sat him in a chair and applied an oxygen mask, but it was only when paramedics arrived that the true extent of the emergency became clear.
Rebecca Schell, counsel assisting the coroner, told the court, "He was immediately repositioned to the ground and CPR was commenced. Prior to CPR, Mr Maine's oral cavity was swept out and food and fabric ribbon were discovered. In total, SAAS officers removed three different pieces of fabric ribbon of varying colours from Mr Maine's airway." He was transferred to the Lyell McEwin Hospital, but he died later that day. The official cause of death was upper airway obstruction by food and foreign material, on a background of frontotemporal dementia.
The inquest is now probing whether more effective first aid or better staff training could have saved his life. "Ultimately, the inquest will consider the issue of whether appropriately administered first aid could have prevented the death of Mr Maine," Schell explained. The court heard that Maine had a history of ingesting inedible objects—clay and pearl beads among them—on three occasions before his death. Enrolled nurse Juvy Rakoia testified, "It's common knowledge that Ron would sometimes be ingesting things that are not food." Yet, when she checked his mouth that morning, she saw nothing unusual. Registered nurse Zijad Softic, who also responded, told the emergency operator, "He's basically, what I can see, he's dying but he's still breathing, probably 6-10 [breaths] a minute." Both nurses described feeling unprepared for the situation, with Rakoia noting, "We checked his mouth, we swipe it out, there's nothing anywhere."
Following Maine's death, Helping Hand conducted an internal review and recommended enhanced basic life support and choking training for all nursing staff. The inquest, still ongoing, will examine whether these measures are sufficient and if the tragedy could have been averted by better protocols or more robust training. Outside the courtroom, Maine's daughter Jessica paid tribute to her father—a devoted Crows fan—and urged families to scrutinize the care options for their loved ones, saying, "If you can't get care from an aged care home, then how can you be sure that your family is going to be safe?"
Across the globe in Belfast, Northern Ireland, another family is grappling with loss after 25-year-old Lee Gannon died from lobar pneumonia at Royal Victoria Hospital in February 2022. As reported by BBC News, Gannon's family called emergency services after he developed severe breathing difficulties. But a series of missteps in the triage process meant he waited nearly four hours for paramedics after the initial 999 call at 12:19 a.m. By the time he reached hospital at 4:13 a.m., cardiac arrest had claimed his life.
Neil Sinclair, chief paramedic officer for the ambulance service, admitted to the inquest that a failure to properly categorize Gannon's condition had "tragic consequences." He said, "The actions of the service had fallen below standard and had tragic consequences for Lee and his family." Emergency medical dispatcher Zena Gardner, who handled the first call, acknowledged, "I should have made it a Category 1." Instead, the call was coded as Category 2—meaning a slower response—after she associated his symptoms with coronavirus rather than ineffective breathing. Gardner confessed, "I don't know why I didn't... it was an error of misunderstanding."
Other dispatchers echoed similar regrets. Andrea Hunter, who answered a later call from Gannon's mother, said, "I should have re-triaged at that stage—definitely... I regret not re-triaging that call." By the time paramedic Eamonn Cunningham arrived, Gannon was unresponsive, and resuscitation efforts failed. The inquest concluded with coroner Maria Dougan set to deliver her findings at a later date, but not before the ambulance service rolled out additional training for call handlers, emphasizing the importance of re-triage and alertness to new information.
Meanwhile, in Dublin, the inquest into the death of 27-year-old Chris Dignam-Healy, nephew of the late Aslan singer Christy Dignam, has highlighted a different kind of obstacle: the physical barriers that can delay emergency care. According to The Irish Times, Dignam-Healy suffered a suspected heart attack while visiting an apartment in Gracepark Manor, a gated development in Whitehall. The initial 999 call was made at 11:51 a.m. on January 23, 2023, and an ambulance was dispatched 19 minutes later. But when the crew arrived at 12:20 p.m., they found themselves locked out, unable to gain access through the gate. Multiple calls to the number that had raised the alert went unanswered, and after waiting for 19 minutes, the ambulance left to attend another incident.
John Guilfoyle, assistant chief officer at Dublin Fire Brigade, testified, "Difficulties in gaining access to gated developments had the potential to cause delays in providing treatment to casualties." He noted that all 14 emergency units were busy at the time, and while the call was classified as a "Priority 1, Delta code"—signaling a life-threatening emergency—the first responders simply couldn't get in. A second ambulance, called at 12:42 p.m., managed to enter the complex via a nearby hotel and reached the patient at 12:53 p.m., but by then, it was likely too late. Dignam-Healy was pronounced dead at the Mater Misericordiae University Hospital at 1:40 p.m., with the coroner citing multiple drug toxicity as the cause of death.
Coroner Cróna Gallagher told the family, "Nobody can answer" whether Dignam-Healy could have been saved if the ambulance had arrived sooner, but she assured them, "everyone did everything to assist him." Still, the inquest underscored the need for better access protocols in gated communities and more robust communication between emergency crews and callers.
These three cases, each unique in their circumstances, point to a broader need for reform and vigilance in emergency care. Whether it's training staff to recognize and respond to choking risks, ensuring that triage systems prioritize the sickest patients, or overcoming physical barriers to access, the lessons are clear. For families left behind, the hope is that these tragedies will spur meaningful change—so that in the next emergency, help arrives not a moment too late.
