AN INQUEST INTO THE DEATH OF SIAUTO ELIUTA TUNUMAFONO

The Coroners Court of the Australian Capital Territory held an inquest into the death of Siauto Eliuta Tunumafono, who passed away on 11 December 2013 at Calvary Public Hospital. The cause of her death remained unascertained, although it was likely due to fatal cardiac arrhythmia. The primary legal issues before the court were whether there was a breach of protocol in the emergency treatment provided to Tunumafono and if such a breach contributed to her death. Additionally, the court was required to determine if a matter of public safety arose from the inquest, as per section 52(4)(a)(i) of the Coroners Act 1997.

The court found that there was indeed a breach of protocol by the ACT Ambulance Service and possibly the ACT Fire and Rescue in not defibrillating Tunumafono when indicated. Despite this breach, the court concluded that it was unlikely to have contributed to her death due to the prolonged time since her collapse. The court acknowledged that multiple factors, such as confusion caused by defibrillator prompts, incompatibility of defibrillators, and the stressful environment, contributed to the errors in treatment. The court made no adverse comments on the individual officers involved but identified the lack of written protocols regarding defibrillation as a matter of public safety.

In response to the inquest findings, the ACT Ambulance Service and ACT Fire and Rescue have taken several measures to address the identified issues, including updating defibrillators, developing protocols for changing defibrillators, and enhancing training and education for staff. The coroner deemed these actions sufficient to address the matter of public safety and decided against making further recommendations. The coroner also expressed a desire for all electronic treatment equipment to be synchronised to a time standard to aid in patient treatment and future investigations. The coroner extended sympathies to Tunumafono's family and friends and planned to publish the findings, recommendations, and comments on the ACT Coroners Court website.