South Australia to implement new patient escalation protocols after patient's death

South Australia is set to introduce new protocols empowering patients and their carers to demand urgent re-evaluations of their medical conditions in hospitals. This initiative follows the tragic death of 33-year-old Ryan Bowman in 2025, whose family felt their concerns were ignored during his final days at Mount Gambier Hospital.

An independent report later confirmed that Bowman's care was delayed and mismanaged. Bowman had a complex medical history, including congenital heart defects, an acquired brain injury, and a past battle with Hodgkin lymphoma. As his condition worsened after being hospitalized with double pneumonia, his mother and stepfather, Deb Brooks and Chris Brooks, found that their detailed knowledge of his medical history was disregarded.

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In our situation, it was the fact that Ryan was end-of-life and we had a plan, but the plan wasn't followed.

"In our situation, it was the fact that Ryan was end-of-life and we had a plan, but the plan wasn't followed," Mr. Brooks stated. "We tried to escalate it and no-one would listen." He believes that an effective escalation protocol could have altered the outcome.

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We tried to escalate it and no-one would listen.

In memory of Ryan Bowman, his family established the Ryan Bowman Legacy of Care Foundation. The foundation actively campaigned for a framework enabling patients to escalate concerns about their hospital care. Their lobbying, alongside other patient advocates, prompted the South Australian government to announce the development of new protocols. These protocols will mandate urgent reviews and are modeled after similar successful initiatives in Queensland, New South Wales, and Victoria.

SA Health Minister Blair Boyer affirmed that the government will develop the South Australian protocols over the coming months, with input from individuals with lived experience. "When families and carers raise concerns, they deserve to be heard," Boyer said. "This protocol will build on lessons from other jurisdictions as we develop an approach that strengthens safety, supports our clinicians and provides greater confidence in our health system."

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When families and carers raise concerns, they deserve to be heard.

Queensland's "Ryan's Rule," established in 2011 after the death of two-year-old Ryan Saunders, serves as a precedent. His parents had voiced concerns about his deteriorating condition, and a subsequent inquest found that medical staff failed to detect and respond to his infection promptly. The Queensland protocol allows patients and their carers to request a clinical review by calling 13 HEALTH.

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This protocol will build on lessons from other jurisdictions as we develop an approach that strengthens safety, supports our clinicians and provides greater confidence in our health system.