She says she waited for three hours at the hospital which did not have antivenom, because “there wasn’t an ambulance driver available” to take her to Northam until 5pm, delivering her to that hospital about 6pm, five hours after she had been bitten. “I vomited all the way to Northam and had a severe headache and pain. I can’t explain how sick I was” Mrs Longmuir said. “After Northam Hospital consulted with Sir Charles Gairdener Hospital in Perth, I was finally given antivenom which I think was about 9.30pm." Mrs Longmuir was transferred to SCGH the following day by ambulance. “I ended up with acute renal failure and thrombocytopenia. I put on 11kgs in fluid in one day, so was rushed on to dialysis. I had to have blood transfusions before they could insert the tube for dialysis because of thrombocytopenia, otherwise I would have bled to death.”

In a clinical review of her case in July 2017, St John Ambulance stated they had found no behavioural or resourcing issues. "Any delays experienced in receiving anti-venom … rest with the clinicians on duty at NRH (Northam Regional Hospital) ED. The time transfers ... requested by the regional hospitals are not influenced by SJA”. But emails from some in the ambulance service show that questions were asked about Mrs Longmuir’s treatment from as early as February 24, 2017. “Stephanie is the sister in law of one of our Koorda volunteers so the concern has also been raised by him regarding delays in getting anti-venom that may be resulting in dialysis and/or kidney damage at the last report from him. One of our Wyalkatchem volunteers has also brought the issue up as was concerned that [Wyalkatchem] couldn’t raise a transfer crew and felt there was a fail in that process,” the email reads. Dissatisfied with her treatment, Mrs Longmuir wrote to the doctor who oversaw her treatment via video link.

In a letter dated April 10, 2017, she received an apology for her “poor experience” from the WA Country Health Service (WACHS). The letter also listed “key issues” including "the presence of a doctor on site, antivenin (also known as antivenom) and laboratory facility access. "This was not present at the Wyalkatchem Health Service and the transfer to a facility that can provide this should be expedited” it read. Fast forward to 2018, and in reaction to the death of Mrs Nicholls and the story of Andrea Williams who was bitten by a snake on September 20 at Marvel Loch, WACHS has rolled out antivenom to 81 sites across the state. But a supply of antivenom alone is not the answer. Treating snake bite requires medical practitioners skilled and trained in the latest techniques, with resuscitation equipment at the ready in case the patient has an adverse reaction to treatment or suffers complications.

Brian Nicholls said his wife Mary had thought that a snake had “passed over her foot when wheeling a wheelbarrow” and although she was “adamant she hadn’t been bitten” when son Stephen inspected her leg, he saw some dried blood on an area of skin exposed near her ankle and treated it as though she had been envenomed. Stephen, who had recently completed a first aid course, bandaged Mary’s leg “from bite to thigh … which was probably the right thing to do,” Mr Nicholls said. Loading The Australian Venom Research Unit at Melbourne University explains why pressure-immobilisation is recommended for snake bite. “Its purpose is to retard the movement of venom from the bite site into the circulation, thus "buying time" for the patient to reach medical care. Research with snake venom has shown that very little venom reaches the blood stream if firm pressure is applied over the bitten area and the limb is immobilised.

"The treating doctor will decide when to remove the bandages. If a significant amount of venom has been injected, it may move into the blood stream very quickly when the bandages are removed. They should be left in position until appropriate antivenom and resuscitation equipment have been assembled. "Bandages may be quickly reapplied if clinical deterioration occurs and left on until antivenom therapy has been effective.” Mr Nicholls said he witnessed the removal of his wife’s pressure immobilisation bandage about 10.30am, shortly after her admission to Wyalkatchem hospital. In an interview on 6PR in October, Stephen Nicholls said the Wyalkatchem hospital did not have antivenom.

According to Mr Nicholls the bite was rebandaged “some time later” but Mrs Nicholls wasn’t given antivenom until the RFDS arrived with it on board at 1.30pm. Dr Timothy Jackson, venom specialist and research fellow at the AVRU says: “They should not have removed the bandage unless they were ready to administer antivenom. You need to be ready to treat the consequence of the removal of the bandage, to observe what changes and be ready for that.” Both Stephanie Longmuir and Brian Nicholls have stated that although they rushed, there was no sense of urgency on arrival at Wyalkatchem hospital. Mrs Longmuir says she waited for three hours, and Mr Nicholls says he and his wife waited at Wyalkatchem for four hours. What is clear is that WACHS and the treating doctor knew of the procedural shortcomings regarding Stephanie Longmuir’s case, acknowledged in correspondence to Mrs Longmuir as far back as March and April 2017. In an email sent on March 9, 2017 to the doctor who treated her via video link, Mrs Longmuir wrote: “I am struggling since the snake bite which I feel was not taken seriously by anyone on my journey to hospital on the 22nd sept. I have had days of headaches vomiting and now have acute renal failure and on dialysis three times a week".

In his reply the following day, the doctor highlighted “what could have been done better”. Loading The list reads: “1. Initial transfer by the GP to a hospital with antivenom and pathology services. 2. Better first aid, good bandage, poor immobility. 3. Poor communication in delay of transfer between Wyalkatchem and Northam.” And yet, Brian Nicholls said staff at Wyalkatchem wanted to send Mary by road to Northam, but that it was the ambulance crew who insisted the RFDS be called. “They were adamant, fly her to Perth” he said.

WACHS says “for patients with significant envenomation, aeromedical transport to a tertiary hospital within the metropolitan area will always be needed". It is worth remembering that the ambulance crews involved are volunteers. Local people who donate their time and expertise to assist the community. But getting crews at short notice can be problematic. Stephanie Longmuir is right to ask why the RFDS was not called to fly her to Perth. It’s one thing to supply the antivenom to the country. But as witnessed by Stephanie Longmuir and Brian Nicholls, there are questions around the capability of some, perhaps only a handful, of medical staff at some (not all) WA country hospitals. There is no doubt that it is hard to staff country hospitals and health services. There is an enormous amount of gratitude from people in the regions to doctors and nurses who elect to serve them.

The hours are long, the work challenging. Medical practitioners, integral to the wellbeing of the community are faced with the full gamut of emergency situations, including snake bite. And the successful treatment of snake envenomation requires skill. It isn’t fair on doctors or nurses if they do not have the latest training, skills or equipment to treat snake bite. In emergencies, good, clear communication and up-to-date medical training is paramount. If any of that is in any doubt, patients should be flown to Perth without delay.