Michelle Daw, Yorke Peninsula Country Times

The harrowing story of an elderly man with a traumatic head injury who died after being sent home from hospital brought the problems plaguing local health into sharp relief at the health inquiry hearing in Wallaroo.

At the Economic and Finance Committee hearing at Wallaroo Town Hall on March 28, Lyn Longo, of Moonta, recounted a series of errors and lack of capacity in health services that led to her husband, Don Longo, 70, dying early the next morning.

On October 5, 2022, the couple had their three grandchildren staying with them in Moonta when he tripped and fell onto a metal anvil, which caused facial bruising, including on his eye and forehead.

An ambulance arrived at the Longos’ home but the crew received another urgent call for a child, so the paramedic negotiated with Mrs Longo and she agreed to take her husband to Wallaroo Hospital. (The child later died.)

Mrs Longo said she provided hospital triage staff with all her husband’s medical information, including his heart condition and use of blood thinners, his list of medications and the fact he had suffered a stroke some years before.

“Despite this information, the severity of the head trauma, and my questions to the locum (doctor) about the strange sound in (Mr Longo’s) speaking voice, the locum put a couple of stitches into his split eyelid and said ‘he’s good to go’ and sent him home with this tube of ointment.

“(There were) no warnings of symptoms to watch out for, no follow-up visits planned or appointments for an X-ray.

“Overnight, his condition worsened.

“His face swelled to monstrous proportions, and he couldn’t talk — all this observed by three small children. It was clear to me and to the grandchildren he was critical.

“Early the next morning, the ambulance was called again with the same paramedic who worked all night and he (Mr Longo) died as he arrived at the hospital.”

Mrs Longo said she was advised of her husband’s death by a phone call from a hospital staffer.

She said some of the many factors that led to his death included inadequate ambulance staffing, leading to delays and paramedics being on duty for at least 12 hours and a reliance on volunteers.

The hospital’s ED was also inadequately staffed and lacked after-hours imaging services, she said.

In her written submission to the inquiry, Mrs Longo said the decision to send her husband home after a severe head trauma rather than keeping him in hospital for 24 hours of observation seemed an “error of unconscionable proportions”.

She said she had been consumed with guilt that she did not insist her husband be kept in hospital overnight or choose for him to be sent to Adelaide for a minor procedure to his eyelid.

The report from the State Coroner indicated the accident was catastrophic, as her husband had suffered cracked vertebrae and internal bleeding and, later, obstruction of his upper airway as a result of the spinal fractures and the fact he was taking anticoagulant (blood thinner) medicine.

Mrs Longo said she was struggling to live with the knowledge that her husband’s last few hours were utterly terrifying as he fought for each breath.

“Perhaps the death was inevitable after such a dreadful fall, but he should have had the resources of a modern hospital system there to ease the pain and fear and to give the survivor comfort that everything possible had been done,” she said.

Widow and daughter push for change

Grieving widow Lyn Longo says she has achieved some peace after her husband’s traumatic death following a series of errors and inadequate care.

Mrs Longo and her daughter, Marie Longo, persisted in getting Yorke and Northern Local Health network to address the issues that led to Don Longo’s death in October 2022.

They secured a meeting in September 2024 with Wallaroo Hospital director of nursing Sue Watkins, YNLHN quality and safety director Fiona Murray, and YNLHN medical services executive director Dr Hendrika Meyer.

In her written submission to the inquiry into health services on Yorke Peninsula, Mrs Longo wrote the following actions had been reported at the meeting:

• The Regional Local Health Network Post Fall Management Protocol, covering all six regional health services in SA, had been revised and now directed admission for all consumers (patients) presenting as Mr Longo had
• A shared learning resource had been developed so that all sites could learn from Mr Longo’s case
• Seven Wallaroo Hospital nursing staff and two educators attended had attended an Emergency Medicine Education and Training program trauma education session
• Two staff who were rostered on the night of Mr Longo’s presentation at Wallaroo Hospital had attended an education program on trauma in older patients
• Education sessions, entitled Trauma Tuesdays, had been introduced at Wallaroo Hospital and all ED staff were encouraged to attend
• A trial of a trauma and fall alert sticker was undertaken at Wallaroo and Maitland hospitals. The use of such stickers was superseded by the introduction across YNLHN of Electronic Medical Records, which have forcing functions for EDs to ensure all triggers have to be considered and entered into the record to ensure appropriate triage. The rollout across all YNLHN sites was due for completion in mid-January 2025.

Mrs Longo said, in addition to these measures, YNLHN had recruited an emergency medicine specialist as an ED director for Wallaroo and Port Pirie Hospitals to provide senior medical expertise.

She was also told YNLHN would continue to advocate the provision of 24-hour CT imaging at Wallaroo Hospital.

“Seeing the changes that are being made give me peace that I have done as much as I can to make my husband’s life count,” Mrs Longo said.

This article appeared in Yorke Peninsula Country Times, 1 April 2025.
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