THOMAS Redman was 18 years old when he died in a rescue helicopter after doctors exhausted Gloucester Hospital's limited blood supplies in 2015 after the teenager smashed his arm through a window.
It was a day and a loss that has "totally overwhelmed our lives", his uncle Peter Redman said after a coroner found limited whole blood supplies in regional and rural NSW was "a big issue" that contributed to decisions and some "misunderstandings" before the teenager's death.
Thomas died in a Westpac Helicopter as it flew north from Gloucester to Taree to pick up blood and refuel more than four hours after his injuries, rather than south for emergency surgery at John Hunter Hospital.
While the decision "would not have changed the outcome for Thomas" because Taree was a shorter distance than Newcastle, there was evidence of a "breakdown in communication" about the purpose of the Taree trip, magistrate Ross Hudson found in a decision on Tuesday after an inquest into the teenager's death.
Mr Hudson found paramedics and doctors provided a high standard of care after Thomas lost up to half his blood at 9.30am on December 16, 2015, when a vein and two arteries were severed after he smashed his arm through a window on a family property at Barrington.
But the teenager's death has prompted significant changes in major trauma case retrieval processes, including retrieval helicopters and ambulances now carrying three whole units of blood rather than two.
Mr Hudson recommended NSW Minister Brad Hazzard prioritise availability of blood clotting products that can be carried by emergency responders at room temperature to assist with extreme bleeding cases in regional and rural areas.
It followed evidence that Gloucester Hospital had only three units of blood available on the day of Thomas's accident, which was a factor in the decision to fly to Taree for more blood before attempting the flight to John Hunter Hospital.
There is "more work to be done around the availability of whole blood, especially in rural and remote areas", Mr Hudson found.
"The issue of whole blood availability is a big issue. Small hospitals like Gloucester would usually only have two or three units of universal donor red cells and they would invariably have no clotting factors."
The inquest was told the Australian Red Cross Blood Service and NSW Ambulance Service are currently "convincing NSW Health Pathology to allow retrieval teams to carry clotting factors".
After Thomas Redman's death it is now mandatory for the state's retrieval consultant to be notified of all extreme trauma cases to provide "critical central oversight".
Mr Hudson said it was "concerning" that paramedics treating Thomas were not aware they could speak directly to the 24-hour on-call state retrieval consultant, and that the consultant was not aware of the teenager's case until more than three hours after Thomas's uncle rang 000.
"The court finds that the state retrieval consultant should have been involved in this most complex case when the helicopter was tasked" half an hour after the 000 call, Mr Hudson found.
The issue of whole blood availability is a big issue. Small hospitals like Gloucester would usually only have two or three units of universal donor red cells and they would invariably have no clotting factors.Coroner's Court magistrate Ross Hudson.
NSW Ambulance has upgraded protocols for the transport of critical cases to hospital, without waiting for rescue aircraft, after the teenager's family criticised the nearly an hour an ambulance was at Barrington waiting for the helicopter.
Thomas was ultimately taken the short trip to Gloucester Hospital by road ambulance after an emergency doctor in the helicopter crew resuscitated the teenager at Barrington when he had a cardiac arrest.
Thomas's mother Jane Redman wept on Wednesday as she remembered arriving home that day.
"I saw the helicopter there. I knew straight away it was Thomas," she said.
"I believe if he was taken to the local hospital straight away and given the blood things would have been different."
Mr Hudson said it was "abundantly clear to the court that Thomas was deeply loved and his family continue to acutely feel his loss".
The teenager's chances of survival were remote "unless he was able to receive the treatment he required without delay", and "even if this treatment was immediately available, survival was unlikely", Mr Hudson said.
"In light of the dynamics and situation which the paramedics were confronted with in the specific set of circumstances detailed and outlined above, the system or decision-making process which led to the order of events regarding the transport of Thomas in dire circumstances, cannot be criticised," he said.
"Unfortunately, this was an extremely unique case, in many regards, and no matter what decision was made regarding transport, the likelihood of Thomas surviving was extremely low."
Mrs Redman said her son, who had a history of mental illness, was "kind-hearted and a beautiful, beautiful boy".
"There's been changes made in the system because of what happened, but that's no comfort to me," she said.