The Health Minister has apologised to a family after a simple typing error stopped an ambulance from reaching a toddler who then suffered a fatal heart attack.
The Ambulance Service of NSW has promised to reform its booking system following the tragedy, which will come before the coroner next month.
"The circumstances which led to the death of this young boy … are tragic," Health Minister Jillian Skinner said.
"I wrote to his parents [the next day] to convey my deep sympathy and support.''
The sick 18-month-old boy, from Tregear in Sydney's west, was taken to a doctor's surgery on the morning of September 9.
A call was made from the doctor's office after 9.10am requesting an ambulance within 30 minutes.
It took one hour and another call before paramedics arrived.
By that time, the boy had entered into cardiac arrest. Despite treatment from paramedics he died at The Children's Hospital at Westmead.
Fairfax Media understands a simple typing error made by a call-taker that morning meant the ambulance was not dispatched. An extra keystroke changed a booking request entered for 9:14 to 19:14 in the system's 24-hour clock.
The calls were not made through triple-0 but a 131-hotline for non-emergency transport, when patients need a supervised journey to hospital but not immediately.
It is understood that emergency calls have times entered automatically, but operators on the 131-hotline can type them in manually.
Ambulance NSW would not say what stopgaps were built into its computer system to catch typing errors, such as a confirmation screen.
It says it will ensure the incident is not repeated by training the staff on its non-emergency hotline to identify when patients are in a critical condition and teaching them about the risks of typing errors.
The doctor's office made a second call for an ambulance, to the same hotline, about 9.55am.
Paramedics arrived about 15 minutes later.
"The patient's condition had deteriorated," said Ray Creen, the chief executive of the NSW Ambulance Service. "A review indicated a NSW Ambulance operator error delayed that transport.
“NSW Ambulance offered our unequivocal apologies and sympathy to the family.’’
Wayne Flint, the president of the Emergency Medical Services Protection Association, said it was ‘‘a really tragic event’’.
‘‘It may have been appropriate to use the triple-0 system to make this call,’’ he said.
The doctor who saw the child declined to comment.
The boy’s funeral was held at a private ceremony the following Thursday, September 13. Attempts to make contact with his family have been unsuccessful.
Neither Mrs Skinner nor the Department of Health answered questions about whether the number of ambulances on the road had increased over the past decade and, if so, by how much.
But Mr Creen strongly denied that this incident was a sign of an overloaded system.
“Ambulance availability levels had no bearing on this incident,” he said.
But paramedics in Tregear said that the station’s two ambulances – and many others – had not been bolstered in response to population growth in the western suburbs.
“Since I’ve been in the job the number of cars has not gotten any better,” one source said. “Sometimes our closest call is maybe 30 or 40 kilometres away.”
An autopsy and a brief of evidence will be prepared for the NSW coroner at an inquest scheduled to begin at the Glebe coroner’s court on December 13.