The Ambulance Service of NSW has promised to reform its booking system after a simple typing error reportedly prevented an ambulance from reaching a toddler who then suffered a fatal heart attack.
On September 9, the 18-month-old Tregear boy was at a medical centre when a call was made for an ambulance at 9:10am, Fairfax reports.
But a typing error meant the ambulance was booked for 19:14, meaning no paramedics were dispatched until another call was made.
By the time the ambulance arrived at the medical centre, nearly an hour later, the young boy had entered into cardiac arrest. Despite being treated by paramedics, the boy died at The Children's Hospital at Westmead.
The request for paramedics was reportedly placed through a non-emergency number where operators enter times manually. This 131-hotline is generally for patients who need supervised transport to hospital but not immediately.
This is opposed to the triple-0 system where times are added immediately and automatically.
NSW Health Minister Jillian Skinner apologised to the family for the fatal error.
"The circumstances which led to the death of this young boy...are tragic," she told Fairfax.
"I wrote to his parents [the next day] to convey my deep sympathy and support."
NSW Ambulance Service chief Ray Creen said changes had been made to prevent a repeat of the death.
"(Call logs) have to be double checked by another operator and confirming the call pick-up time with the caller," he told ABC radio on Friday.
Mr Creen says the service is investigating whether the manual logging system for non-urgent calls can be replaced by technology, reports the ABC.
"We're looking at how we can automate that," he said.
"At this stage we're not sure how that can be done, given the variances of pick up times that the non-emergency system requires."
Internal and independent investigations are expected to lead to further changes to prevent future tragedies.
"It's made recommendations that I've accepted so far as investigating further technology fixes and changing the call-taking questions we ask of doctors for non-emergencies," Mr Creen said.
"So we'll be implementing them as soon as we can."
The case is expected to come before the NSW coroner next month.