An ambulance was 700 metres away when Kylie Jane Cay died from a ruptured spleen four days after being bashed by her partner, a court has heard.
A Coroner’s Court of Victoria inquest that began on Monday is investigating why Ambulance Victoria cancelled the dispatch after Ms Cay called triple-0 reporting she was in pain with difficulty breathing.
Ms Cay’s partner Justin Turner was convicted in 2017 by the Supreme Court of manslaughter and sentenced to a maximum 12 years jail.
The court heard Ms Cay hid from him in a dog kennel after he punched her in the face, fractured her ribs, and hit her feet with a hammer.
He dragged her by her hair and she was terrified that she would kill him, she told police after the vicious attack.
She told police he assaulted her most days and had previously choked her until she lost consciousness.
After attending hospital after the attack on June 18, 2016, the 44-year-old was medically assessed as fit for release after two days care.
But in the following days, she developed a ruptured spleen from the blunt force trauma of Turner’s attacks, an autopsy later found.
She was discovered dead in her Port Fairy home on June 22.
Twelve witnesses are listed to give evidence at the inquest, which is attempting to determine if Ms Cay’s death was preventable.
It will investigate why Ambulance Victoria downgraded the call made before her death and cancelled the ambulance that had been dispatched to help her.
It will also investigate whether Corrections Victoria should have done more to keep Turner away from Ms Cay, considering the mother-of-three had a court order in place against him at the time.
Counsel assisting the coroner Rishi Nathwani said there were four investigations currently before the coroner’s court of deaths where noncompliance with court orders was involved.
WHY WAS AMBULANCE CANCELLED?
Haunting audio played to the court on Monday revealed one of Ms Cay’s final conversations before her death.
The recording of the triple-0 call was between Ms Cay’s friend, the operator, and Ms Cay.
Ms Cay is heard answering “yes” when asked if she has difficulty breathing.
Her friend told the operator: “She just got out of hospital – she was belted.”
“She’s in pain and she needs to go to the hospital.”
The operator is heard reassuring the women: “They’re on their way.”
The operator told Ms Cay to wait in a comfortable position and prepare any medications she needed to take with her.
“If she does get worse in any way call us back immediately,” she said.
The friend is heard saying “No worries love, thank you” before the call ended.
But when the notification about Ms Cay’s condition left triple-0 — run by an organisation called ESTA — and arrived with Ambulance Victoria, it was downgraded from a code one to a code three and the ambulance was cancelled.
Instead, a paramedic called Ms Cay to review her condition.
During this call, Ms Cay seems to have become frustrated and hung up, Mr Nathwani told the court.
There was no attempt to call her back, he said.
The Ambulance Victoria clinician responsible for downgrading the code and cancelling the ambulance dispatch told the court he stood by his decision.
Daniel Staff told the court he regularly downgraded 12 to 15 ambulances dispatched by triple-0 in a typical 14-hour shift.
He said Ms Cay had been to hospital four days earlier and difficulty breathing was common in patients who had broken their ribs.
“The decision was reasonable given the clinical information available at the time,” he said.
He said it was reasonable to think she had most likely run out of analgesic, a painkiller commonly given to patients with broken ribs.
“I considered a reasonable course of action to downgrade and refer,” he said.
He said he did not have time to read additional information provided about Ms Cay’s case by triple-0 because “it would take two or three minutes”.
After Mr Staff downgraded the priority for Ms Cay, it was the responsibility of a separate Ambulance Victoria team to call her and follow up.
“All are accredited and qualified to perform the duty of expert secondary triage,” he said.
“It was in that system I placed my trust.”
Audio of the call between Ms Cay and the secondary triage team is expected to be played at a future hearing.
HUNDREDS OF CODES
The inquest’s first witness on Monday was ESTA representative Jessica Taylor, who told the court Ambulance Victoria was provided with a code that indicated Ms Cay’s condition after her triple-0 call.
ESTA is a separate organisation to emergency services, and is responsible for receiving information from triple-0 callers and communicating that information to the relevant emergency service.
She said Ambulance Victoria was not specifically told Ms Cay was having difficulty breathing.
But she said her case was allocated an event code and “the event type made it clear that the patient had difficulty breathing”.
Lawyer representing Ambulance Victoria, Paul Halley, told the court there were “about 400” different codes that paramedics could receive from ESTA.
Codes are generated through the answers to a series of questions ESTA asks a caller such as if they are bleeding, having difficulty breathing or in pain.
Ms Thomas agreed it was true there was “no mention of difficulty breathing” but “from ESTA’s point of view that’s been captured in the code”.
“How would you expect an Ambulance Victoria operator to know what every code was?” he said.
“I can’t answer that,” she answered.
Lawyer acting for Ms Cay’s family, Stella Gold, asked Ms Thomas if she was “surprised” by the suggestion that Ambulance Victoria operators were not expected to know what all of the codes sent to them by triple-0 meant.
“I don’t have an opinion on that,” she said.
Ms Gold told the court that records indicated an ambulance was 700 metres away from Ms Cay when the ambulance dispatch order was cancelled.
The inquest continues.