A coroner investigating the death of a teenage bushwalker has recommended that all emergency call centre operators for the ambulance service have access to paramedical advice.


After Sydney Grammar School student David Iredale became lost in the Blue Mountains, he made five triple-zero calls to the NSW Ambulance Service, pleading for help.

He advised them of roughly where he was lost and said he was without water, had fainted and could not walk far.

An inquest into his death has been told he encountered sarcasm and a lack of empathy from the operators, who failed to pass on key information and properly log the calls.

He is believed to have died a short time after his last call.

NSW Deputy State Coroner Carl Milovanovich handed down his findings, recommending that all ambulance emergency operators have access to “paramedical advice”.

“This inquest has identified that in all the calls David Iredale made to triple zero … there was a lack of empathy and call takers lacked the skills … to record vital information that was crucial,” Mr Milovanovich said.

He said there had been “a lost window of opportunity that could have resulted in a different outcome”.

Among the other recommendations was a call for a widespread review of the training and protocols for ambulance triple-zero operators.

Milovanovich said Emergency Services Minister Steve Whan should set up a working party of police, ambulance, fire brigades, National Parks and Wildlife Service and Telstra representatives to examine the issues.

“I was astonished that at no time after the death of David Iredale … did the NSW Ambulance Service conduct a review or analysis of its performance in this matter,” the coroner said.

“It is astonishing that a person can ring the ambulance service on five occasions … and no satisfactory review be undertaken.”

He has also called for written authorisation to be a pre-requisite for expeditions taken under the Duke of Edinburgh scheme, more publicly available information on water sources in NSW wilderness areas, and promotion of the use of personal locator beacons for bushwalkers.

He praised the “poise and dignity” shown by David\’s parents, Stephen and Mary Anne Iredale, throughout the inquest.

He found David had died “primarily because he ran out of water”.