South Australia's State Coroner David Whittle released findings on Monday, July 13, 2026, concerning the death of 64-year-old David Low, who passed away on February 25, 2020, due to heart complications and other health issues including diabetes and morbid obesity.

The inquest, held in December 2024, examined the procedures followed by the South Australia Ambulance Service (SAAS) when attending Mr. Low's home. It found that despite being informed that Mr. Low was inside and in need of urgent medical attention, an attending paramedic chose not to force entry into the house. This decision was attributed to a "flawed understanding" of the paramedic's legal powers to enter the property.

Mr. Low's carer had contacted SAAS after Mr. Low sounded "really distressed and was grunting in pain" during a phone call, which abruptly ended when he apparently dropped the phone. Intensive care paramedic Darryl Sparrow, with 20 years of experience, was on scene but did not gain entry. An expert analysis of data from Mr. Low's pacemaker estimated that he died between 4:18 pm and 4:39 pm, during which time Mr. Sparrow was outside the house.

Although Coroner Whittle concluded that Mr. Low's death was "unlikely to have been preventable," he issued eight recommendations aimed at improving emergency response protocols. Six recommendations were directed to South Australia's Minister for Health and Wellbeing, and two to the Minister for Police.

Coroner Whittle noted that while some procedural references had improved, they still lacked clear guidance on the extent of powers SAAS members are expected to exercise, necessitating further research and clarification.

A government spokesperson emphasized the importance of the findings, stating, "As the coroner said, the fact that Mr Low’s death was unlikely to be preventable does not diminish the importance of our emergency services understanding and being supported to use the power of authorised entry."

Sources