Recent coronial findings and administrative reviews in South Australia and Scotland have identified critical failures in emergency medical dispatch and the execution of forced entry protocols.

南澳州與蘇格蘭最近的死因研訊與行政審查發現，在緊急醫療派遣與強制進入協定的執行方面存在嚴重失效。

In South Australia, a coronial inquest conducted by State Coroner David Whittle examined the death of David Low on February 25, 2020. The proceedings established that an intensive care paramedic, Darryl Sparrow, failed to exercise statutory powers of entry despite evidence of the patient's distress. The Coroner noted that the paramedic's understanding of the Health Care Act was deficient, having acquired procedural knowledge via 'osmosis' rather than formal study. Consequently, entry was deferred until the arrival of a family member. Although the Coroner concluded the fatality was likely inevitable, he identified a systemic failure in the application of entry powers. This led to eight recommendations, including the provision of forced-entry equipment for ambulance and police vehicles and the establishment of liability immunity for SAAS personnel to facilitate more decisive action.

在南澳州，由州死因裁判官 David Whittle 主持的死因研訊調查了 David Low 於 2020 年 2 月 25 日的死亡事件。程序確定，儘管有證據顯示患者處於危險狀態，一名重症監護救護員 Darryl Sparrow 未能行使法定進入權限。裁判官指出，該救護員對《醫療保健法》的理解不足，其程序知識是透過「耳濡目染」而非正式學習獲得。因此，進入被推遲至一名家屬到達後才進行。儘管裁判官結論認為死亡可能是不可避免的，但他認定在行使進入權限方面存在系統性失效。這導致了八項建議，包括為救護車與警車提供強制進入設備，以及為 SAAS 人員建立免責機制，以促進更果斷的行動。

Parallel systemic deficiencies were observed in Scotland regarding the death of Brian Hurton on November 18, 2025. Evidence indicates that Mr. Hurton initiated two emergency calls reporting severe respiratory distress and impending collapse. In both instances, call handlers deferred immediate ambulance dispatch in favor of a clinician callback, citing regional service saturation. A subsequent review by Healthcare Improvement Scotland determined that the initial call was incorrectly prioritized. The failure to assign a high-priority code resulted in a dispatch delay of approximately three and a half hours. The Scottish Health Secretary, Angela Constance, characterized the incident as a failure in call handling, while the Scottish Ambulance Service has since accepted the findings of the Significant Adverse Event Review (SAER).

在蘇格蘭 Brian Hurton 於 2025 年 11 月 18 日的死亡事件中，也觀察到平行的系統性缺陷。證據顯示，Hurton 先生發起了兩次緊急電話，報告嚴重呼吸困難及即將昏迷。在這兩次情況中，接線員均以區域服務飽和為由，將立即派遣救護車推遲，改由臨床醫生回電。隨後由蘇格蘭醫療改良局 (Healthcare Improvement Scotland) 進行的審查確定，最初的電話優先級分級錯誤。由於未能分配高優先級代碼，導致派遣延遲約三個半小時。蘇格蘭衛生大臣 Angela Constance 將此事件定性為接線處理失效，而蘇格蘭救護服務 (Scottish Ambulance Service) 隨後接受了重大不良事件審查 (SAER) 的結果。

Both jurisdictions have acknowledged procedural lapses and are currently implementing revised policies to improve emergency response efficacy.

兩個司法管轄區均已承認程序失誤，目前正實施修訂後的政策，以提高緊急應變的效能。