Preface

I’ll never forget the first time I was alerted as a GoodSAM responder. During my final year of Paramedicine study, I was due to go on shift with NSW Ambulance at 11am during my penultimate placement.

The alert came through at 07:15 on a Thursday morning and I was on scene three minutes later at a house on the corner of a main road, opposite a service station. The patient, an elderly grandmother, had collapsed in a narrow passage between a downstairs bedroom and the toilet where she had collapsed. Her granddaughter was doing CPR, but the narrow passage made it ineffective. The family were distressed and CPR was being directed by the 000 call taker on speaker. I took over the scene, confirmed arrest, and with help moved the patient to get proper access. I administered an airway, and asked the teenage grandson to check for an AED at the service station despite one not on the GoodSam AED map. He came back empty-handed.

There were five AEDs within 1.5 kilometres of us: one at a church, at a GP surgery, another church, a primary school, and a community centre but none were accessible. None of the organisations were due to open for at least 40 minutes. Even if they were open, or the AEDs accessible, the round trip time especially in morning traffic, was too long to make a difference.

So we worked the arrest with what we had; CPR, an airway adjunct, a bag-valve mask, and untrained bystanders, until the ambulance arrived 15 minutes after me. We never achieved ROSC.

What struck me was the absence of the one intervention most likely to change the outcome: defibrillation, not any failure of clinical care.

A few months later, I was alerted by GoodSam again. This time at 1am. This patient lived about 600 metres from my house and I arrived just before the ambulance. Again, there were AEDs nearby and again, none were accessible at that time of night.

This patient, however, had a shockable rhythm, and despite rapid response across empty streets, we didn’t get a defibrillator onto him until 15 minutes after his arrest. Even so, we achieved ROSC, but ultimately he died in the ED.

These experiences changed how I think about cardiac arrest. Despite my clinical training, despite my passion in cardiology and research in all the amazing clinical interventions we wield, BLS, ALS, retrieval and eCPR, it strikes me that this is a system design problem.

We have trained responders, established protocols and proven technology. We simply don’t have alignment between where cardiac arrests occur and where defibrillators are available. Surely the biggest impact we can make to survivability of OHCA is tweaks to what happens after the ambulance arrives, but how quickly we can defibrillate and get high quality CPR happening?

For every minute that passes without defibrillation, the chance of survival from cardiac arrest decreases by 7 to 10 percent.

American Heart Association, Early Defibrillation Advisory Statement [1]

A note on data labels

Every quantitative claim in this report carries one of four provenance labels so the reader can see exactly what kind of signal is being used. The table below names the four labels and the treatment each implies.

Label	Meaning
OBSERVED	Figure taken directly from a published or curated source.
ESTIMATED	Planning-grade scenario output; bounded, explicit assumptions.
SYNTHETIC	Demographic proxy; pending verification against NSW Ambulance data.
INFERRED	Candidate geometry derived from SA2 centroids; not dispatch-grade.

Chapter 02

Executive Summary

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Thesis. A drone-delivered AED network could meaningfully improve out-of-hospital cardiac arrest survival across NSW by closing the residential response-time gap that fixed public-access AEDs cannot reach. The rural and regional case is arithmetically stronger than metro alone, because the ambulance response-time deficit is larger at those tiers and the survival uplift from a 4-minute drone is therefore more leveraged. A funded 12-month three-site, three-tier pilot (Metro / Regional / Rural NSW) is the appropriate next step to test whether the modelled benefits hold under Australian operational conditions.

Confidence level. Feasibility-stage. The time-survival relationship is well established; the operational, regulatory, and bystander-retrieval variables are not yet measured in Australian conditions at any of the three tiers.

Three key findings.

1. Across the three-tier pilot the model estimates 21 to 86 additional lives per year within the covered population, depending on bystander-retrieval rate (100% retrieval down to 30%) and decay-parameter sensitivity (±20% on the Valenzuela-Larsen survival curve). The Rural per-event case is the strongest (Cat-1 response deficit more than doubles the Metro deficit); the Metro tier delivers the largest absolute volume.
2. The hardware-loaded 5-year envelope for a five-base network is _{$1.5M; the fully-loaded operating envelope across the three-site pilot is} $3–5M base ($2M optimistic through $8.5M pessimistic) once CASA approval, dispatch integration, staffing, insurance, evaluation, community engagement, and tier-varied regulatory work are priced (Chapter 09 BOM).
3. Cost per QALY spans ~$450 to $5,500/QALY across the operating-model envelope, an order of magnitude below published public-access AED benchmarks of $30,000–$55,000/QALY at every point in the range [2].

Three unresolved risks.

1. CASA approval for medical-delivery BVLOS over populated areas is case-by-case and has no Australian precedent at this specific payload class. Tier-stratified: the Metro pilot site is the hardest submission; Rural is simpler because the airspace is uncontested and the SORA-AU ground-risk class drops (Chapter 11).
2. Bystander AED retrieval at scale has been demonstrated once globally (Karolinska/Everdrone 2021). Australian rates are unknown and may differ between Metro, Regional, and Rural bystander populations — the three-tier pilot measures this directly.
3. NSW Ambulance dispatch integration across three sites is a non-trivial negotiation rather than a technical fact; station-based siting at each tier depends on a formal co-location memorandum of understanding.

The specific pilot ask. A funded 12-month three-site pilot at Campbelltown (Sydney metro) + Port Macquarie (Regional) + Far West / Broken Hill (Rural), estimated at ~$3–5M all-in, delivering tier-stratified response-time comparison against ambulance, bystander retrieval rates, and preliminary clinical-outcome data to inform the scaled deployment decision (Chapter 12).

Download the briefing for your audience.

• Services Proposal (PDF) — for NSW Ambulance, NSW Health, NSW Rural Health, and government readers
• Investment Feasibility (PDF) — for capital partners and unit-economics readers
• Research Proposal (PDF) — for academic collaborators and grant reviewers

These caveats constrain the claim but do not overturn the survival-time evidence base. The relationship between time-to-defibrillation and survival from shockable cardiac arrest is among the most replicated findings in emergency medicine: faster defibrillation saves lives. The open question is whether drones can reliably deliver that speed advantage in Australian conditions across Metro, Regional, and Rural NSW, at a fully-loaded cost the sponsor can absorb, under a regulatory posture CASA will accept. A funded three-tier pilot is the only credible way to find out.

Chapter 03

Spatial distribution of cardiac arrest in NSW

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A defibrillator-carrying drone network is, at heart, a spatial optimisation problem: where the events occur dictates where the bases must be, and how far a drone must fly to reach each new collapse. This chapter characterises the spatial distribution of out-of-hospital cardiac arrest (OHCA) across NSW. It uses three observed sources — BHI Healthcare Quarterly ambulance activity and response times at SA3, the NSW Ambulance Cardiac Arrest Registry state-aggregate outcomes, and the ABS ASGS 2021 Remoteness Area classification — alongside the retained modelled demand allocation score documented in Appendix M.

Three-tier framing. Candidate pilot sites are stratified into three tiers using the ABS Remoteness Area classification. Metro covers Major Cities of Australia, with Sydney, Newcastle, and Wollongong ranked as separate metros. Regional covers Inner Regional and Outer Regional Australia. Rural covers Remote and Very Remote Australia. The statewide three-tier candidate ranking names a top-1 headline plus top-2 secondary candidate per tier, with the metros split three ways; the ranking dataset is carried in the reproducibility appendix, and the final set will be re-run when restricted NSW Ambulance registry data is received.

The Greater Sydney SA2 analysis described below is retained as the Metro(Sydney) view, and is now one of three Metro read-outs rather than the whole picture. Two complementary views are shown below: a rate choropleth that normalises for population (task 3.3), and a proportional-symbol map that reports absolute event volume (task 3.4). Read together, they reveal a pattern that is not obvious from either map alone.

Synthetic-cohort caveat. The figures and rankings below descend from a proxy dataset that combines the ABS 2021 Greater Sydney SA2 population and age structure with the ABS 2021 SEIFA Index of Relative Socio-economic Disadvantage (IRSD), anchored to a Hasselqvist-Ax 2015 incidence base rate. The derivation is documented in full in Appendix M: Methodology: synthetic OHCA proxy with SEIFA IRSD weighting. Treat every absolute count on this page as pending verification against NSW Ambulance incident data; relative ordering between SA2s is expected to hold under replacement with the real cohort.

Where rates concentrate

The SA2 polygons sit on a muted Sydney base map (CartoDB Positron, © OpenStreetMap contributors) showing the coastline around Sydney Harbour, Botany Bay, the Parramatta and Georges rivers, and the principal road network, so readers can locate the hotspots against a recognisable geography. The data layer uses a ColorBrewer 5-class sequential-reds palette. Dark shading clusters across Sydney’s south-west corridor (Fairfield, Cabramatta, Bankstown, Campbelltown); the palest shading covers the northern shore and the outer growth LGAs such as Kellyville and Rouse Hill where the IRSD decile is high and the age-65+ share is low. A signal-red callout ring marks the highest-rate SA2. A quantile legend, scale bar, north arrow, base-map attribution line, and data-provenance footnote sit adjacent to the map.

Key insight. Rate concentration is a joint geography of age and disadvantage. Under the SEIFA-IRSD-weighted proxy (Appendix M), the highest synthetic rates sit in Sydney’s south-western corridor: Fairfield, Cabramatta–Lansvale, Bankstown, Campbelltown-South and Campbelltown-North all land in the top quantile. Age structure still matters, but the IRSD weighting pulls the rate surface decisively away from the leafy northern-shore band the earlier age-only proxy highlighted. The policy implication is inverted from that earlier reading: a “wealthy boomers” heuristic would mis-site base placements away from the SA2s the combined age-plus-deprivation signal actually prioritises. The choropleth also carries the full MAUP caveat: re-aggregating the same cohort to SA3 or LGA boundaries would smooth the south-west cluster into a single mid-range polygon, and pooling across LGA would re-introduce the wealthy-suburb age-signal artefact.

Where the volume sits

The 37 centroid circles sit on a muted Sydney base map (CartoDB Positron, © OpenStreetMap contributors) showing coastline and the principal road network so each symbol reads against a recognisable Sydney geography. Circle sizes range from small (tens of synthetic cases in wealthier northern SA2s) to large (more than 200 synthetic cases in the south-west cluster led by Fairfield, Bankstown and Cabramatta–Lansvale). Three signal-red callout rings label the top-ranked hotspots. A graduated-circle legend shows minimum, midpoint, and maximum case counts, with a Viridis class key underneath. Scale bar, north arrow, base-map attribution line, and a data-provenance footnote sit adjacent to the map.

Key insight. Volume and rate now point at the same part of the city, the disadvantaged south-west. The top-three SA2s by synthetic volume (Fairfield, Bankstown, and Cabramatta–Lansvale) between them carry approximately 16% of synthetic cases, and the top-five extends this cluster south to Campbelltown-South and Campbelltown-North. Every SA2 in the top-five sits in SEIFA IRSD decile 1 or 2 (most disadvantaged), confirming that the combined age-plus-IRSD proxy is the logical first-pass driver of drone-base placement. Note the deliberate encoding: a choropleth would misrepresent this view because event counts (as opposed to rates) are an extensive variable and must not be mapped by area fill. The proportional symbol map is the cartographically honest form for the question “where are the biggest hotspots, in absolute terms?”

Candidate bases: ambulance stations versus synthetic SA2 centroids

The set-cover coverage model in chapter 07 relies on a candidate pool of possible base locations. The original pool was synthetic SA2 centroids anchored on the top-10 SEIFA-weighted hotspots. That pool is defensible as a first-pass modelling exercise but it invites the obvious counter-question from a reader at NSW Ambulance: why not base drones at existing ambulance stations? Co-location reuses electrical supply, security, and 24/7 crewed presence, and it simplifies the dispatch-integration story since the drone is launching from the same site the paramedic crew already works from.

A hand-curated pool of 44 NSW Ambulance stations inside the Greater Sydney bounding box provides a first-class candidate pool, hand-curated from the NSW Ambulance public station directory cross-referenced against OpenStreetMap amenity=ambulance_station records. The file sits at the NSW Ambulance station reference dataset (reproducibility appendix); licence and source attribution are carried in the CSV header.

Base map is CartoDB Positron at 0.75 opacity. Blue-grey diamond markers show the 34 stations that were not picked; signal-red diamonds highlight the 10 picked by the greedy set-cover run at 6 km service radius. Grey circles sized by synthetic annual OHCA count show the demand surface. Station locations are observed; assignment of drones to those stations is a modelling choice pending NSW Ambulance operational agreement.

Running the same greedy set-cover algorithm over the three candidate pools, at the 6 km base-scenario service radius, produces the comparison in Table 3.1.

The full base-by-base rollout for each pool and each radius scenario lives in the coverage-results dataset (reproducibility appendix) .

Key insight. Anchoring candidate bases on the existing ambulance-station network lifts peak coverage from roughly 51% to roughly 70% at the 6 km base radius, because the station network is denser and more geographically spread than the 10-hotspot synthetic pool, so the greedy rollout has more productive candidates to choose from before saturation sets in. The hybrid pool does not beat the station-only pool at 6 km, because the first ten hybrid picks are all stations; at the optimistic 8 km radius the hybrid pool edges past station-only (85% versus 79% of city envelope) because the synthetic centroids fill a small Campbelltown-south gap the station network does not cover as tightly. The result should be read as a sensitivity pass, not a re-baselining: the synthetic-centroid numbers remain the headline planning envelope because they are the pool the project has calibrated against, and the station-pool numbers depend on NSW Ambulance agreeing to co-location, which is a negotiation rather than a technical fact.

Caveats and next steps

Both maps draw on the synthetic cohort only; neither represents observed NSW Ambulance incident data. Under the current methodology the synthetic proxy is SEIFA-IRSD-weighted; the derivation, the Hasselqvist-Ax 2015 base-rate anchor, and the pending-verification labelling convention are documented in Appendix M: Methodology: synthetic OHCA proxy with SEIFA IRSD weighting. The synthetic counts remain above the n < 5 suppression threshold for every SA2, so no cells are suppressed, but rates are not age-standardised and will need Empirical Bayes smoothing when the real cohort is slotted in. The nearest-centroid raster proxy used in Figure 3.1 is a presentational stand-in for ABS SA2 polygons and is explicitly labelled as such on the map itself. The final report build will swap in the true SA2 geometry and re-run the quantile classification; the class breaks will shift slightly but the south-west cluster is expected to survive the substitution because the ranks are carried by the underlying rates, not by the polygon shapes.

Out-of-hospital cardiac arrest kills roughly 30,000 Australians each year [3]. That is more than breast cancer. More than prostate cancer. More than road trauma. In Greater Sydney alone, the model estimates approximately 4,800 events per year [ESTIMATED], concentrated not in public spaces but inside private homes. Over 70% of OHCA occurs in residential settings [3].

The majority of out-of-hospital cardiac arrests in Australia occur in private residences, where publicly accessible AEDs are rarely available.

AIHW, OHCA Annual Report [3]

The clinical science is settled. For every minute without defibrillation, survival from witnessed ventricular fibrillation drops 7-10% [5,6]. The American Heart Association recommends defibrillation within 3-5 minutes of collapse [1]. Bystander defibrillation before EMS arrival is associated with 53% 30-day survival for shockable rhythms. Without it: 16% [7]. That is the difference between a patient who walks out of hospital and a patient who does not leave.

And yet.

In at least one regional NSW community, the aspiration has been to place an AED within 200 metres of every resident. In Orange, the Heart of the Nation charity, founded by cardiac-arrest survivor Greg Page after his 2020 collapse, worked with Orange City Council to install defibrillators in every town park, with councillors unanimously backing the plan [8,9]. The ambition is sound: saturate the public AED footprint so that no cardiac arrest occurs beyond arm’s reach of the one device proven to change outcomes. On its face, this is the obvious solution. Put enough devices in enough places and the problem disappears.

It does not disappear. It reveals a paradox with three dimensions.

Scale and cost

What is achievable in a compact regional town does not transfer to a metropolitan area of five million people spread across 12,000 square kilometres. Placing an AED within 200 metres of every resident in a regional centre requires a manageable number of devices in a concentrated geography. Replicating that density across Greater Sydney, from Penrith to Cronulla, from Campbelltown to the Northern Beaches, would demand tens of thousands of units, each requiring purchase, installation, signage, registration, and ongoing maintenance including battery replacement and pad expiry [ESTIMATED]. The capital outlay alone would run into the tens of millions. Maintaining currency across that fleet, ensuring every device is charged, in-date, and functional at the moment it is needed, would constitute a programme of work in its own right.

Scaling to a metropolitan area is qualitatively different from scaling within a compact regional town; the coordination cost grows non-linearly, the maintenance burden compounds, and the marginal return diminishes. The last 10% of coverage, covering cul-de-sacs, acreage blocks, and isolated pockets between commercial strips, costs disproportionately more than the first 90%.

Awareness, access, and use

Even where AEDs exist, three barriers stand between the device and the patient.

Awareness. The bystander who witnesses a cardiac arrest must know that an AED is nearby. Most do not. Public-access AED registries exist, but cardiac arrest does not wait for someone to consult a database. The 000 call-taker may direct a bystander to the nearest registered device, but the bystander is already managing CPR, managing panic, managing a dying person on the floor. Knowledge of AED locations is not widely held in the community, and under the cognitive load of a cardiac arrest, even known information becomes difficult to retrieve.

Access. The AED must be physically reachable. An AED mounted inside a surf club is not reachable at 06:42 on a Tuesday morning. An AED in a school is not reachable before 08:30 or after 15:30 or during holidays. An AED in a GP surgery is not reachable on weekends. An AED in a community centre 400 metres away requires a round trip of five to eight minutes on foot, and that assumes the bystander leaves the patient to go looking [OBSERVED]. Five AEDs within 1.5 kilometres, none accessible. That is the pattern described in the preface of this report, replicated across suburban Sydney every week.

Willingness and competence to use. Even when a bystander locates and reaches an AED, they must be willing to apply it to a human being in extremis. Public anxiety about using AEDs remains high despite their design for lay use [5]. Fear of causing harm, uncertainty about legal liability, and unfamiliarity with pad placement are all documented barriers to bystander defibrillation in the literature. The device is forgiving; the psychology is not.

Measurable outcomes

The most difficult dimension. Does saturating an area with AEDs produce measurable improvements in survival? Proximity alone does not complete the chain of survival. A defibrillator that is purchased, installed, registered, maintained, located by a bystander, accessed within minutes, and correctly applied can save a life. Remove any link and the chain fails. AEDs work, unambiguously [7]; the open question is whether a fixed-installation strategy translates proximity into actual use, and actual use into population-level survival gains.

The evidence is mixed. Public-access defibrillation programmes in high-traffic locations such as airports, casinos, and sports arenas have demonstrated clear survival benefit [5]. These are environments with trained staff, high footfall, and rapid recognition. Residential settings share none of these characteristics. The patient collapses at home, often in the early morning, often alone or with a single household member who may themselves be elderly. The nearest AED is behind a locked door. The chain of survival breaks at the same link every time: the device does not reach the patient.

The paradox, then, is this: the aspiration to place an AED within 200 metres of every resident is clinically sound but operationally insufficient. It cannot scale to a metropolitan area at reasonable cost. Where it does exist, awareness, access, and willingness erode the benefit. And even where every barrier is cleared, the evidence for population-level survival gains from fixed residential AED installations remains inconclusive.

This is a system design problem. The devices exist, the evidence for early defibrillation is unambiguous, and the clinical protocols are established. What is missing is a delivery mechanism that matches the geography and timing of the events themselves: residential, dispersed, and time-critical. The following section examines how current emergency response systems perform against that requirement and where they fall short.

Campbelltown South is an SA2 in Sydney’s outer southwest. Disadvantage decile 1. Population 11,200. Detached housing: 82%. Residents aged 65 and over: 14.5% [10]. Streets of single-storey brick and tile homes set back from the kerb. Driveways with two cars. Low front fences. Quiet before seven.

06:42. A 71-year-old man steps out of the bedroom and collapses in the hallway [SYNTHETIC]. His wife hears the fall from the kitchen. She finds him unresponsive on the carpet, not breathing normally. She does not know what cardiac arrest looks like. She knows something is wrong.

06:43. She calls 000. The dispatcher recognises the pattern within 40 seconds: unresponsive, abnormal breathing. The call is coded as suspected cardiac arrest. Two things happen simultaneously. The dispatcher begins telephone CPR instructions, talking the wife through chest compressions on the hallway floor. And the dispatch system triggers a drone from the nearest candidate base, approximately 5 kilometres away [SYNTHETIC].

06:44. The drone is airborne. Cruise speed: 100 km/h [ESTIMATED]. It flies a direct path, unimpeded by traffic lights, school zones, or the roundabout on Narellan Road. The wife is on her knees doing compressions. They are shallow and fast. The dispatcher corrects her tempo.

06:47. The drone arrives overhead. Audio and visual alerts activate. The AED descends to the front yard. Three minutes from launch.

06:48. The wife retrieves the AED. She opens it. The device talks to her. Peel the pads. Place them on his bare chest. Analysing. Shock advised. She presses the button. First shock delivered at approximately six minutes from collapse [ESTIMATED].

At six minutes, the survival probability for a shockable rhythm is roughly 36% [ESTIMATED, derived from [5]; P = 0.67 x exp(-0.10 x t), t = 6].

06:53. The ambulance arrives. Paramedics take over with advanced life support. The AED has recorded two shocks and six minutes of CPR data. The patient has a pulse.

Now remove the drone.

06:42. The same collapse. The same hallway.

06:43. The same 000 call. The same telephone CPR. No drone dispatch.

06:53. The ambulance arrives carrying the first defibrillator. Eleven minutes from collapse. The wife has been doing compressions for ten minutes. She is exhausted. Compression depth has dropped.

At eleven minutes, survival probability is roughly 22% [ESTIMATED, same model, t = 11].

The difference: 14 percentage points. In a population where roughly one in five attended OHCA presents with a shockable rhythm [3], that difference is not abstract.

The drone did not replace the ambulance. The paramedics still arrived at 06:53. The clinical handover still happened. What changed was the six minutes between collapse and first shock. Those six minutes are the entire intervention.

This scenario is synthetic. The SA2 is real. The survival curve is evidence-based. The question it raises is not.

The preface to this report is a first-person account of two GoodSAM activations in Sydney, both without a reachable defibrillator in time. That chapter is the lived experience. This one is the programme evidence that sits underneath it. Trained-bystander-responder systems are already operational in NSW and Victoria. They work. They also reveal, with some precision, the gap that an AED-delivery layer is meant to close.

What GoodSAM is

GoodSAM (Good Smartphone Activated Medics) is a smartphone application that notifies registered off-duty responders (paramedics, nurses, doctors, CPR-trained laypeople) when a suspected cardiac arrest is reported to the emergency-call service within a defined radius. The responder can accept, decline, or ignore the alert. On acceptance, the app routes them to the patient and, where relevant, to the nearest registered public-access AED. Dispatch of the ambulance is parallel, not contingent on the alert. The app originated in the United Kingdom and has since been adopted by several Australian state ambulance services, as well as services in Europe and North America.

Where it is deployed

In Victoria, Ambulance Victoria launched GoodSAM in 2018 alongside a public AED registry [11]. In New South Wales, NSW Ambulance launched the programme on 23 November 2023; at the 12-month review it had 8,372 registered responders with 1,745 recorded on-scene arrivals [12]. By early 2026 the NSW roll had grown past 13,500 registered responders and the service had publicly credited the programme with 100 lives saved [13]. Comparable systems run in London, the English East Midlands, Stockholm, Copenhagen, and parts of the Netherlands and Germany.

What the evidence says about clinical impact

Three peer-reviewed signals are worth citing directly. A Stockholm randomised trial of mobile-phone dispatch found that bystander-initiated CPR rose from 48% in the control arm to 62% in the intervention arm, a 14-point absolute increase from a single software layer [14]. A 2022 analysis of GoodSAM across London and the English East Midlands (5,237 confirmed OHCAs) reported that when a responder accepted an alert, the adjusted odds of survival to hospital discharge were 3.15× in London (95% CI 1.19–8.36) and 3.19× in the East Midlands (95% CI 1.17–8.73) [15]. The most recent Victorian evidence, a 2018–23 cohort of 9,196 OHCAs, found that when a smartphone-activated volunteer arrived before EMS, the patient was 8× more likely to receive bystander CPR, 16× more likely to receive bystander defibrillation, and had 37% higher odds of survival to hospital discharge [16]. Across the same two decades in Victoria, the share of OHCAs receiving bystander CPR rose from 40.3% in 2003–04 to 72.2% in 2021–22; Utstein-comparator survival to discharge roughly tripled [11]. Earlier Victorian work on the AED-registry layer sits alongside these findings as a precedent for public-access defibrillation in the same jurisdiction [17].

When a responder accepted an alert, the adjusted odds ratio for survival to hospital discharge was 3.15 in London and 3.19 in the East Midlands.

Smith et al., European Heart Journal — Acute Cardiovascular Care [15]

The Sydney gap this paper addresses

Two points matter for the rest of the argument. The first: the responder layer is built. A trained person can be in the hallway inside three to five minutes of an alert in a well-populated part of Sydney, as Chapter 01 records. The second: what that responder cannot do, in more than seven out of ten Sydney residential arrests, is arrive with a defibrillator in their hand. Public-access AEDs cluster in the places where GoodSAM responders are least likely to need them (commercial strips, transport interchanges, sports venues), and are behind locked doors at night and in the early morning, which is when a large share of residential events occur [3]. The outcome gap is payload delivery, not awareness or willingness.

How drone-AED delivery complements, rather than replaces

GoodSAM gets the responder to the scene. A drone-AED layer gets the defibrillator to the scene. The two vectors run in parallel and arrive independently; neither one replaces the ambulance, and neither one replaces the other. International evidence has already shown that airborne AED delivery can beat EMS to the patient in more than two-thirds of suspected OHCAs in a live operational setting [18], and at least one documented save now exists in which the drone-delivered device was used by a bystander before EMS arrival [19]. The question this paper poses is narrower and more local: given that Sydney already has a trained-responder layer and an AED registry, what would it take to add a dispatched-defibrillator layer, and what would the incremental survival benefit be in the residential geography where GoodSAM is already active?

That is the question the chapters that follow address.

Out-of-hospital cardiac arrest does not strike uniformly. It clusters, driven by age, population size, and social disadvantage. To estimate where burden falls across Greater Sydney, we built a synthetic demand surface across 37 SA2 areas, selected for geographic spread and demographic diversity [3,10].

NSW records approximately 4,800 OHCA events per year in Greater Sydney [ESTIMATED from state-level reporting]. No publicly available dataset geocodes these events to suburb level. We allocated an annual total of roughly 4,200 cases across the 37 project SA2s using the SEIFA-weighted proxy documented in the Methodology chapter: event counts are proportional to population, to the age-65+ share, and to a SEIFA IRSD decile weight that is highest in the most disadvantaged areas [10,20]. The resulting event counts are synthetic; they reflect demographic plausibility under an explicit formula, not verified incident locations [SYNTHETIC].

The five highest-burden SA2 areas under this model:

A pattern emerges. The five SA2s carrying the highest estimated burden all sit in IRSD decile 1 or 2 (the most disadvantaged end of the SEIFA distribution), and each carries a sizeable resident population with a meaningful age-65+ share [10,20]. Disadvantage correlates with higher rates of chronic cardiovascular disease and, in many areas, with longer ambulance response times. Older populations carry elevated cardiac arrest risk independent of geography.

These top five SA2s alone account for roughly 1,035 of the ~4,200 allocated annual events, close to a quarter of the total demand concentrated in about an eighth of the study areas [SYNTHETIC].

A transparency note on what this surface can and cannot show. The proxy is a model, not a measurement. It is built from ABS 2021 Census inputs and a linear SEIFA IRSD decile weighting; it is not de-identified NSW Ambulance incident data, and every absolute count on the page should be read pending that validation. What a proxy like this can show is the demographic shape of risk: which SA2s concentrate the joint load of population, age, and disadvantage the published literature associates with OHCA [3]. What it cannot yet show is the actual spatial point pattern of incidents, the street-level timing, or whether a protective factor (preventive cardiology access, earlier bystander response) partially offsets demographic risk in a given suburb. Resolving the gap between the two is a validation task against NSW Ambulance records, flagged in the Methodology chapter and in chapter 11’s risk register; relative SA2 ordering is expected to hold under replacement with the real cohort, absolute counts are not.

This demand surface is not dispatch-grade. It cannot tell us which street will see the next cardiac arrest. What it can do is identify the zones where drone positioning would intercept the greatest number of events, given demographic realities. For feasibility scoping (deciding where to place a small number of bases and estimating population-level coverage) this resolution is sufficient. Operational deployment would require geocoded incident data from NSW Ambulance, a step beyond the boundary of this analysis.

The surface is a planning tool. It tells us roughly where to look, not precisely where to land.

A drone on a launchpad covers nothing. Coverage depends on where bases are placed and how far each drone can fly within the critical response window. We modelled base placement using a greedy set-cover algorithm: place the first base where it captures the most OHCA events, then place each subsequent base to maximise the incremental gain [ESTIMATED].

Using a 6 km service radius as the base scenario:

The full coverage-by-base series across conservative / base / optimistic scenarios is carried in the coverage-results dataset (reproducibility appendix).

The first two bases deliver 21.3% coverage. Doubling to five bases does not double coverage; it reaches 40.0%. By ten bases, each additional site adds only two to three percentage points. Diminishing returns set in after five.

We tested three radius scenarios. Under a conservative 4 km radius, reflecting headwinds, airspace restrictions, or heavier payloads, coverage contracts at every fleet size. Under an optimistic 8 km radius, coverage expands, but the shape of the diminishing-returns curve stays the same. Across all scenarios, service radius is the dominant parameter. Whether a drone can reach 6 km or only 4 km matters more than whether the network has seven bases or ten. This finding directs attention toward aircraft performance and airspace access as the binding constraints on real-world effectiveness.

All radii are geometric great-circle distances from base to SA2 centroid. They do not account for controlled airspace boundaries, terrain obstacles, weather, or flight-path routing. Operational coverage will be smaller than these estimates.

Staged rollout

The coverage model supports a staged deployment, not because caution is a virtue in itself, but because sequencing is the fastest way to generate usable evidence.

Stage 1 positions two bases in the highest-burden SA2 clusters. Two bases cover an estimated 21.3% of annual events [ESTIMATED], enough to generate statistically meaningful response-time data within 12 to 18 months. This stage validates flight operations, dispatch integration, and real-world delivery times against the geometric estimates.

Stage 2 extends to five bases, guided by Stage 1 operational data. If actual service radii prove shorter than 6 km, the algorithm re-optimises placement. If certain areas show access constraints (controlled airspace near Kingsford Smith, for instance), the model reallocates those bases. Five bases at validated parameters are worth more than ten placed on unchecked assumptions.

Stage 3 scales toward ten bases only if Stage 2 demonstrates worthwhile incremental gains at confirmed operational radii.

This is risk reduction through sequencing. Each stage produces data that sharpens the next.

If bases are co-located at ambulance stations

The coverage numbers above use a synthetic pool of candidate base locations anchored on the top-10 SEIFA-weighted OHCA hotspots (chapter 03). A more operationally realistic candidate pool is the existing NSW Ambulance station network: co-locating drones with paramedic crews reuses electrical supply, 24/7 security, and site access, and it simplifies dispatch integration. Chapter 03 describes the station pool; the base-by-base rollout lives in the coverage-results dataset (reproducibility appendix).

Running the same greedy set-cover algorithm against the 44 NSW Ambulance stations inside the Greater Sydney bounding box at 6 km service radius, the staged-rollout picks are:

The staged progression above covers a similar geography to the synthetic-centroid plan, with south-western Sydney dominating the first three picks, but routes every base through an existing operational site rather than a greenfield cradle. That distinction matters for the cost envelope (chapter 09), the operating-model integration (chapter 10), and the risk register (chapter 11). It does not displace the synthetic-centroid numbers used as the planning headline; it sits alongside them as a realistic deployment variant pending NSW Ambulance agreement to co-location.

Cardiac arrest survival is a race measured in minutes. The relationship is not linear but exponential decay.

The model follows the form P = 0.67 × exp(-0.10 × t), where P is survival probability and t is minutes from collapse to first defibrillation. This draws on Valenzuela et al. 1997 [5] and Larsen et al. 1993 [21], both establishing the steep, time-dependent decline in survival for ventricular fibrillation and pulseless ventricular tachycardia. It is one of the most replicated findings in resuscitation science.

The numbers at specific response times:

At 4 minutes, the modelled drone delivery target, survival probability sits in the 40–50% range once the ±20% decay-parameter sensitivity is applied. At 8.5 minutes, the Greater Sydney Cat-1 ambulance response median, it falls to the 24–34% range. At the Rural-tier Cat-1 response median of roughly 18 minutes, it drops below 11% — the survival window has effectively closed before ambulance arrival, which is the substantive reason the rural-tier case is so much more leveraged than metro. Every additional minute costs roughly 7–10 percentage points. The curve does not negotiate. [ESTIMATED]

Bystander defibrillation before EMS arrival was associated with a 30-day survival rate of 53 percent, compared with 16 percent when defibrillation was delayed until EMS arrival.

Hasselqvist-Ax et al., NEJM [7]

Not all cardiac arrests benefit equally from rapid defibrillation. Only about 22% of OHCA patients present with shockable rhythms (VF/VT) on first assessment [3]. The remaining cases require CPR and advanced life support but will not convert with a shock alone. The lives-saved estimates below apply only to that shockable subset.

Three-tier contribution to the pilot envelope

The three-site three-tier pilot covers a covered-population envelope drawn from observed BHI ambulance activity at each site. Applying the Valenzuela-Larsen survival function to the shockable subset within that envelope produces a pilot-scale lives-saved contribution per tier:

The pilot envelope sums to a model-wide headline range of 21 to 86 additional lives per year across the covered population. The lower bound spans the pessimistic tail of both the bystander-retrieval-rate sensitivity (30% retrieval across all tiers) and the decay-parameter sensitivity (−20% on the published curve). The upper bound spans the optimistic tail (100% retrieval × +20% on the curve).

The three tiers contribute asymmetrically across the range. Rural supplies the most per-event survival lift (the Cat-1 deficit is largest there), but a relatively modest absolute count because the underlying OHCA volume is lower. Metro supplies the largest absolute count but the smallest per-event lift because Cat-1 response is already competitive. Regional sits in the middle on both axes. The pilot measures all three.

These are modelled estimates, not observed outcomes. The survival function is well established, but the decay rate parameter (0.10 per minute) is derived from international studies, not calibrated to NSW conditions. Varying the parameter by ±20% shifts the base-case lives-saved estimate by approximately ±25% and is the lower-bound component of the 21–86 headline range.

Bystander retrieval sensitivity. The figures above assume that every drone delivery results in successful bystander retrieval and AED application, a 100% retrieval rate. This has been demonstrated once in a real-world case [19] but has not been tested at scale. If bystander retrieval succeeds in only 50% of deliveries, the pilot-scale lives-saved estimate falls to roughly half the 100%-retrieval figure. At 30% retrieval it falls to roughly a third. Even at pessimistic retrieval rates the intervention produces meaningful impact; the assumed retrieval rate is nonetheless the single largest source of uncertainty in the survival model, and the three-tier pilot is the mechanism by which Australian tier-stratified retrieval rates are measured for the first time [ESTIMATED].

Actual benefit depends on operational performance: whether the drone launches, whether the AED is retrieved, whether a bystander applies it correctly — and the pilot measures all three, per-tier.

External evidence supports the direction. A Swedish registry study of 30,000+ cases found that bystander defibrillation before EMS arrival produced 53% 30-day survival, compared with 16% when no bystander defibrillation occurred [7]. In 2021, the Karolinska/Everdrone AED delivery pilot recorded the first documented case of a drone-delivered AED saving a life [19]. That single case does not prove scalability. It confirms the mechanism works outside a simulation.

The gap between a survival probability of roughly 29% at ambulance response and roughly 45% at drone response is the window this proposal targets, and the Rural-tier gap between sub-11% at ambulance response and 45% at drone response is the window where the intervention is most leveraged.

The hardware-loaded cost for a five-base network over five years is approximately $1.5 million [ESTIMATED, hardware-loaded]. This covers platform acquisition, AED units, ground infrastructure, maintenance cycles, and the managed-BVLOS pilot-staffing estimate. It does not include regulatory compliance, dispatch-system integration, community engagement, independent clinical evaluation, insurance, or operational overhead. Those categories are priced below in the fully-loaded bill of materials.

Across the lives-saved sensitivity envelope (Chapter 08: 21 lives at 30% bystander retrieval through 69 lives at 100% retrieval, with a further ±25% from the Valenzuela-Larsen decay-parameter sensitivity) and the operating-model envelope (managed-BVLOS base through one-pilot-per-aircraft pessimistic), the modelled cost per life saved spans approximately $4,500 to $55,000, and the cost per quality-adjusted life year spans approximately $450 to $5,500/QALY [ESTIMATED, operating-loaded bands].

Those numbers look favourable. They deserve scrutiny rather than celebration.

For context: published evaluations of public-access defibrillation programmes report costs in the range of $30,000 to $55,000 per QALY [2]. The drone model appears to outperform those benchmarks substantially. That gap should prompt caution. It likely reflects what the model does not yet capture.

The hardware cost inputs are drawn from published platform specifications and manufacturer pricing where available. They are feasibility-grade numbers, not procurement quotes. Opex assumptions come from operational analogues, not contractual rates. A funded pilot would produce different numbers once real variables (staffing requirements, insurance, maintenance contracts, airspace compliance) are factored in.

Several cost categories sit outside the current model entirely. CASA regulatory engagement for BVLOS approvals requires specialist aviation consulting. Dispatch integration with Triple Zero and state ambulance services involves technical and contractual work that cannot be costed from published data. Community engagement to support bystander retrieval is a programme cost, not a hardware cost.

A second axis sits alongside those exclusions: the operating model. Chapter 10 commits to a phased path from day-1 remotely-piloted managed BVLOS to autonomous flight at scale; the OpEx envelope differs across the phases. The table below reprices the five-year operating cost under three modes, holding hardware, AED units, maintenance, and infrastructure constant and varying only pilot-staffing assumptions.

The ~$1.5M planning envelope quoted at the top of this chapter sits inside the managed-BVLOS band; it is neither the one-pilot-per-aircraft floor nor the autonomous-at-scale optimum. The cost-effectiveness claim in the executive summary depends on the managed-BVLOS mode being the achievable day-1 posture and on the autonomy transition happening on a plausible horizon. If the pilot is forced onto one-pilot-per-aircraft for the full five years, the cost per QALY rises materially; if autonomy arrives sooner than modelled, it falls. The full operating-mode cost series is queued for the cost-model dataset (reproducibility appendix) in the pilot-design phase where real staffing rates and CASA-approval conditions become contractable.

Fully-loaded cost bill of materials

The hardware-loaded envelope at the top of this chapter is the cost of acquiring and running the drone platforms. The fully-loaded envelope is what a funded pilot would contract against; it adds the categories a sponsor would expect to see priced. The chart below shows base value per category sorted by pessimistic-end cost, with whiskers spanning the pessimistic-to-optimistic range and bar colour encoding scope tier.

The same data as a row-by-row table for readers who prefer to see the underlying numbers:

Every row above is a feasibility-stage placeholder sourced from feasibility-stage analogues, not contracts. The pessimistic / optimistic columns bracket the operating-model envelope discussed below; the source-audit appendix (tracker #87 RTW-003) anchors each row against a named source. Read the table as a scope discipline, not a procurement quote: the $1.5M hardware-loaded number in the executive summary is real, but it is not the budget a funded pilot would contract against; the operating-loaded total is.

A third axis sits alongside the operating mode: where the bases are physically sited. Chapter 03 and chapter 07 describe the ambulance-station candidate pool (see chapter 07). Co-locating drones at existing NSW Ambulance stations materially reduces the site-acquisition, security, and round-the-clock-staffing components of CapEx and OpEx. The stations are already owned or leased by NSW Ambulance; they already carry graded electrical supply, fencing, CCTV, and crewed 24/7 presence. A greenfield cradle on a council rooftop incurs site-lease negotiation, a separate security build, and either a standalone uptime contract or a share of an on-call field-service roster. Order-of-magnitude, avoiding those three line items removes roughly 20 to 30 percent of the five-year non-airframe CapEx and a comparable slice of OpEx, though the real figure depends on NSW Ambulance’s own tenancy terms and has to be contracted rather than modelled. The headline ~$1.5M planning envelope does not book that saving today; a station-co-located pilot would have room to absorb the dispatcher-integration and community-engagement costs the current model excludes without the total creeping above that envelope.

The full base-by-base cost-versus-coverage series is carried in the cost-model dataset (reproducibility appendix), with lifecycle breakdown in the cost-model dataset (reproducibility appendix) and sensitivity envelope in the cost-model dataset (reproducibility appendix).

The honest framing: the model suggests the intervention is likely cost-effective relative to existing defibrillation access programmes, and the margin appears large enough to absorb significant cost escalation before the value proposition collapses. But the current figures are a planning envelope, not a budget. They should inform the decision to invest in a pilot. They should not be quoted as operational costs.

Three drone platforms and two AED units form the shortlist from the device evaluation conducted for this study. Each was scored against a weighted heuristic covering the operational factors most relevant to suburban AED delivery.

Drone Candidate Evaluation

Candidates were scored across six dimensions: payload capacity (25%), range (20%), regulatory readiness (20%), operational maturity (15%), maintainability (10%), and cost (10%). Each dimension was scored 1–5 and weighted to produce a composite score. The weighting reflects a feasibility-stage priority: the platform must carry the AED (payload), reach the patient within the service radius (range), and operate legally in Australian airspace (regulatory readiness).

DJI FlyCart 30. A heavy-lift multirotor designed for industrial cargo operations. The FlyCart 30 carries up to 30 kg (comfortably accommodating any AED with payload margin), with a practical range of 16 km and a cruise speed of 72 km/h. It has the strongest operational maturity record in industrial settings and benefits from DJI’s established maintenance and support ecosystem. Its limitation is range: at 16 km, it covers a smaller service radius than fixed-wing alternatives. Estimated unit cost: US$90,000. [OBSERVED]

Wingcopter 198. A fixed-wing VTOL platform purpose-built for medical logistics. The Wingcopter 198 carries 6 kg to 75 km range at 100 km/h cruise speed, offering the widest coverage radius from a single base of any candidate. It holds medical logistics certifications in multiple international markets. The trade-off is cost (approximately US$250,000 per unit) and a specialist maintenance footprint that requires dedicated technical staff. [OBSERVED]

Swoop Aero KITE. Designed for sustained healthcare logistics in distributed networks, particularly remote and low-infrastructure corridors. The KITE carries 4 kg to a maximum range of 175 km at 120 km/h. It has operational history through UNICEF partnerships in Malawi and the Pacific [22]. Its regulatory readiness in Australian suburban airspace is less established than the other candidates. Estimated unit cost: US$150,000. [OBSERVED]

The full scored platform comparison, including per-criterion scores and the composite weighting, is carried in the device-shortlist dataset (reproducibility appendix).

All three platforms are VTOL-capable, meaning they can launch and land without a runway, a requirement for suburban base operations. None has been evaluated against CASA Part 101 BVLOS requirements for Australian suburban airspace. The cost figures are pre-procurement estimates and should be treated as indicative only.

AED Candidate Evaluation

AED candidates were scored across five dimensions: bystander usability (30%), regulatory readiness (20%), maintainability (20%), cost (15%), and recall history (15%). The heavy weighting on usability reflects the operational reality: the AED will be used by untrained bystanders under extreme stress, not by clinicians.

ZOLL AED 3. Weighs 2.5 kg with IP55 environmental protection. Rated for untrained bystander use with real-time CPR feedback via voice and visual prompts. Integrated paediatric mode reduces the number of electrode configurations that need to be stocked. Five-year battery and electrode shelf life minimises maintenance burden. Estimated unit cost: US$2,300. [OBSERVED]

Stryker LIFEPAK CR2. Weighs 2.0 kg with IP55 rating. Provides adaptive audio guidance that adjusts instruction pacing based on user interaction. Bystander-rated with strong global distribution and service network. Four-year battery and electrode life. Higher unit cost at approximately US$2,500, but the strongest vendor support infrastructure of any candidate. [OBSERVED]

The full AED candidate comparison is carried in the device-shortlist dataset (reproducibility appendix).

Both AEDs are within the payload envelope of all three drone candidates. Both are TGA-listed or equivalent-family listed for the Australian market. The selection between them is a procurement decision that should be deferred to the pilot design phase, where hands-on bystander testing can inform the choice.

Operating model: autonomous, remotely piloted, or both?

A serious reader asks the question early: is a human flying each drone, or is the aircraft navigating itself? The answer shapes pilot staffing, the CASA approval path, the liability story, and the unit-economics curve as the network scales. This section states the proposed answer and the reasoning.

The feasible configurations sit on a spectrum. At one end, a single licensed remote pilot controls one aircraft for the duration of each flight (one-pilot-per-aircraft remotely piloted, RP). In the middle, one pilot supervises several aircraft flying pre-planned corridors, intervening only on exception (managed BVLOS, sometimes called one-to-many RP). At the far end, aircraft fly autonomously under dispatcher oversight, with pilots on standby for contingencies rather than on the stick for every flight. Each mode carries a different regulatory approval, a different staffing model, and a different cost-per-flight.

The recommendation is phased. Day-1 operations should run as RP-managed BVLOS: licensed remote pilots operating under a Remote Pilot Operator Certificate (ReOC) issued by CASA under Part 101, with a specific Operations Approval for medical-delivery BVLOS over populated areas [23,24]. Autonomous operation at scale is the target configuration once regulatory posture and operational track record mature. The rationale follows.

CASA’s current approval posture for autonomous operations over residential areas with a medical payload is cautious. Populated-area BVLOS approvals are granted case by case, evidenced by a Specific Operations Risk Assessment aligned with JARUS SORA (SORA-AU), and existing approvals in Australia concentrate on pilot-supervised operations rather than pilot-out-of-the-loop autonomy [23,25]. Wing’s Logan QLD operation is the longest-running autonomous suburban delivery programme in Australia and remains the reference point for what residential-overflight autonomy under Part 101 currently looks like [26]. International analogues sit at similar maturity: Manna Aero’s Dublin operation runs autonomous last-mile flights under Irish Aviation Authority approval, which uses a SORA-equivalent framework [27]; Swoop Aero and Zipline operate pilot-supervised autonomy in Malawi, Rwanda, and the US [22,28]. No operator ships residential-overflight medical AED delivery on a pilot-out-of-the-loop model today.

Against that backdrop, committing to full autonomy at pilot-launch would be unrealistic. RP-managed BVLOS is the realistic day-1 mode because (a) it aligns with CASA’s existing approval frame, (b) it carries lower ground-risk and air-risk classifications in the SORA-AU assessment, (c) it preserves the pilot-in-command liability chain that NSW Ambulance and other health-system partners will expect, and (d) it puts a trained human in the loop during the period where dispatcher integration, community engagement, and weather-stand-down thresholds are still being calibrated. The operational precedent research backs this pattern: Scalea et al.’s peer-reviewed organ-transport work operated under a pilot-in-command model precisely for these reasons [29].

Autonomy becomes the cost-at-scale unlock rather than the day-1 posture. Once dispatch integration and bystander-retrieval protocols are evidenced, once CASA has inspected the operator’s track record under managed BVLOS, and once the fleet and corridor volume justify it, the operating model shifts toward one pilot supervising several aircraft and then to fully autonomous flight with dispatcher oversight. The regulatory engagement plan in chapter 11 structures CASA submissions so each stage builds the evidence the next stage requires. Chapter 09 shows the OpEx consequence: RP-per-aircraft staffing is the cost driver at small fleet sizes, and the path to favourable cost per QALY depends on the autonomy transition happening within a plausible horizon.

The operating-model recommendation pairs naturally with a second station-basing deliverable: basing drones at existing NSW Ambulance stations rather than at greenfield rooftop cradles. Chapter 03 and chapter 07 describe the station-candidate set-cover run; the integrated day-1 configuration is managed-BVLOS pilots operating from a small set of ambulance stations, launching drones into pre-planned corridors from the same site the paramedic crew dispatches from. That pairing is what an NSW-Ambulance-integrated realistic configuration actually looks like: the regulatory pathway (RP-managed BVLOS under CASA Part 101 [23,24]), the site posture (co-located at existing stations with graded power, fencing, and 24/7 crewed presence), and the operational hand-off (dispatcher co-located with the pilot and the paramedic crew) all line up under a single operating unit. The alternative, autonomous flight from greenfield cradles across the suburban rooftop footprint on day 1, stacks every unresolved regulatory, siting, and integration risk simultaneously, which is why neither this report nor the Australian operating precedent (Wing’s Logan programme [26]) recommends that path.

Operational Precedents

Two programmes provide the closest analogues to what is proposed here.

The AED was delivered by drone to the scene before the ambulance arrived, and was used by a bystander to deliver a shock that restored a normal heart rhythm.

Schierbeck et al., New England Journal of Medicine [19] — describing the Gothenburg incident

The Everdrone/Karolinska AED delivery pilot in Gothenburg, Sweden, integrated drone AED dispatch with the national 112 emergency system. Drones were dispatched simultaneously with ambulances to suspected OHCA. In at least one documented case, the drone arrived before the ambulance and a bystander retrieved and applied the AED, resulting in survival [19,30]. The median drone arrival was three minutes ahead of ambulance in pilot areas.

Zipline’s national medical drone logistics network in Rwanda has operated continuously since 2016, completing hundreds of thousands of deliveries of blood products and medical supplies [28]. Rwanda’s airspace regulatory environment differs significantly from Sydney’s, but the programme demonstrates that sustained autonomous medical drone logistics is operationally feasible at national scale.

Regulatory Context

CASA Part 101 provides for BVLOS approvals but requires case-by-case assessment against specific operational risk profiles [25]. No blanket pathway exists. Sydney’s proximity to Kingsford Smith Airport and established helicopter routes creates a regulatory context with no direct international precedent. International approvals may inform but will not determine Australian outcomes.

The estimates above depend on assumptions untested in Australian suburban conditions. Some carry enough uncertainty to invalidate the modelled benefits entirely. Acknowledging this is the reason a funded pilot, rather than direct deployment, is the appropriate next step.

CASA BVLOS approval (high risk). The concept requires beyond-visual-line-of-sight drone operations in suburban airspace. CASA Part 101 permits BVLOS under case-by-case assessment, but the Swedish and Rwandan precedents may not transfer to Greater Sydney’s controlled airspace [25]. Sydney’s proximity to Kingsford Smith Airport, helicopter routes, and dense suburban terrain creates a regulatory context with no direct precedent. Mitigation: the regulatory pathway is a Remote Pilot Operator Certificate (ReOC) issued by CASA under Part 101, extended by a specific Operations Approval for medical-delivery BVLOS in populated areas [23,24]; an early scoped pre-application discussion with CASA, built around a geographically bounded trial corridor, is the entry point rather than the end state. Populated-area BVLOS of this kind typically requires a Specific Operations Risk Assessment aligned with the JARUS SORA methodology and adapted to CASA’s domestic framework (SORA-AU), covering ground-risk and air-risk classes, mitigations, and a Concept of Operations document that CASA can accept before any flight approval is granted [25]. A community-consultation and stakeholder-engagement workstream on overflight and noise for residential Sydney runs in parallel with the technical regulatory submission, not behind it; overflight in suburban airspace is not policy-incidental, and social licence is part of the approval path, not an afterthought. For the avoidance of doubt this is a Part 101 unmanned-aircraft operation with a specific Operations Approval; Part 137 (aerial application / agricultural work) does not apply to medical delivery and the two are frequently conflated by reviewers, which is worth stating explicitly rather than assuming. We acknowledge that this is non-trivial regulatory work rather than a solved problem; the mitigation is a credible pathway, not a completed certification.

Operating-model transition (medium risk). The operating model in chapter 10 is phased: day-1 flights run as remotely-piloted managed BVLOS and the target configuration at scale is autonomous flight with dispatcher oversight. Two transition risks attach. First, CASA may decline to move the operator from managed BVLOS to pilot-out-of-the-loop autonomy on the horizon the cost model assumes, in which case the long-run OpEx envelope shifts upward; Wing’s Logan QLD autonomous operation is the nearest Australian reference point, and its approval took several years of inspected flight time [26]. Second, staffing a managed-BVLOS operation at the day-1 volumes assumed here depends on a thin local pool of ReOC-certified pilots with medical-payload BVLOS experience. Mitigation: structure CASA submissions so each managed-BVLOS flight-hour milestone builds the evidence the next autonomy step requires; budget for pilot-training pipeline investment as part of the pilot-design phase rather than assuming an external market supplies certified pilots at ambulance-service rates.

Bystander retrieval (high risk). The survival model assumes someone at the scene collects the AED from the drone and applies it. This has been demonstrated once in a documented real-world case [19]. It has not been tested in Australian settings, with Australian bystander populations, under Australian dispatcher protocols. If the AED arrives but nobody applies it, the intervention produces no benefit. Mitigation: dispatcher-assisted retrieval protocols, where the 000 call-taker coaches the bystander through collection and pad placement in real time. Community awareness programmes alongside any pilot.

Weather and environmental reliability (medium risk). Wind, rain, and temperature extremes reduce drone range, stability, and battery performance. Published specifications describe optimal-condition envelopes. Suburban Sydney weather is generally mild but includes storm events and high winds that may ground flights. Mitigation: define a weather operating envelope with clear stand-down thresholds. Accept that the network will not achieve 100% availability and model expected downtime.

Synthetic demand model (medium risk). The OHCA demand surface is a proxy model built from demographic indicators. It does not use real incident locations. Coverage claims are geometric, not flight-path validated [SYNTHETIC]. Mitigation: validate against de-identified NSW Ambulance cardiac arrest data before operational commitment.

Cost estimates (medium risk). All cost figures are pre-procurement. Real costs will differ, and the current model likely understates total programme cost. Mitigation: treat the cost envelope as a planning range, not a budget. Conduct detailed costing during pilot design.

Ambulance-station co-location (medium risk). Chapters 03, 07, 09, and 10 all lean on the assumption that drones can be based at existing NSW Ambulance stations rather than at greenfield rooftop cradles. That assumption drives the station-pool coverage numbers, the cost-envelope reduction in chapter 09, and the integrated operating-model narrative in chapter 10. Station-based coverage depends on NSW Ambulance agreeing to co-location, which is a negotiation rather than a technical fact: tenancy terms, floor-space availability, electrical-supply load, and workplace-health-and-safety approvals all sit with NSW Ambulance, and none is modelled here. Mitigation: treat the ambulance-station candidate pool as a sensitivity pass rather than a baseline; the headline planning numbers throughout the report remain anchored on the synthetic SA2-centroid pool, and any operational commitment to a station-based siting plan waits on a formal co-location memorandum of understanding from NSW Ambulance.

Each risk has a corresponding validation gate. CASA engagement resolves regulatory feasibility. A controlled trial resolves retrieval assumptions. Weather logging resolves availability. Registry data access resolves the demand model. Vendor engagement resolves cost.

The appropriate response to these uncertainties is to design a pilot that resolves them, not to wait for perfect data.

The clinical science of out-of-hospital cardiac arrest is clear about where the survival gains sit: the first few minutes, before the ambulance arrives. Research funding does not reflect that geometry. Dollar for dollar and paper for paper, the money flows to the hospital end of the chain: mechanical CPR, extracorporeal life support, drug protocols, advanced airway management, and post-ROSC neuroprotection. The defibrillation link, the single biggest survival lever, receives a fraction of the attention.

This is not an attack on in-hospital research. Those advances matter. The argument is about marginal returns: the same dollar, spent earlier in the chain, buys more survival.

Post-arrival research dominates the portfolio

A decade-long analysis of NIH-funded cardiac arrest grants found that cardiac arrest research received roughly $91 per annual US death, against $2,100 per death for heart disease and $2,200 for stroke, a twenty-fold disparity at the headline level [31]. Within that already-small envelope, the allocation is skewed again. A structured audit mapping NIH cardiac arrest grants against the American Heart Association’s top ten science gaps found that “the majority of grants have focused on optimization of post-cardiac arrest care (78 grants; 45.3%), prediction of patients at risk of cardiac arrest (12; 7%), and developing tools for early neuroprognostication (7; 4.1%),” while dispatcher-directed CPR, a gap with clear survival upside, received no funding at all [32]. A follow-up study using the chain-of-survival framework reached the same conclusion: the later links dominate the spend [33].

The pipeline analysis that followed showed why the imbalance persists. Stroke research, a comparable time-critical cardiovascular condition, attracts roughly ten-fold more federal grants and six-fold more mentored K awards than cardiac arrest research, thinning the pool of early-career investigators able to push the pre-arrival agenda [34]. The Australian picture echoes the US one. An analysis of NHMRC grants (2013–2023) and Heart Foundation grants (2020–2024) found NHMRC allocated roughly 60% of its cardiac arrest envelope to prevention, with the Heart Foundation directing 43% of its smaller pool to pre-hospital care; Australia still spends about AUD $887 per cardiac-arrest death on research, against AUD $4,673 per breast-cancer death [35].

The annual NIH investment in cardiac arrest research is low relative to other leading causes of death in the United States and has declined over the past decade.

Coute et al., J Am Heart Assoc (2017) [31]

Pre-arrival interventions remain under-studied

Publication volume tells the same story as grant allocation. A PubMed query run for this report (2026-04-21) returned roughly 1,606 papers indexed under “extracorporeal cardiopulmonary resuscitation” and 1,299 papers on “targeted temperature management” in cardiac arrest. The same database returned 387 papers on “public access defibrillation” and 136 on “dispatcher-assisted CPR.” Bystander-applied defibrillation, the intervention that most directly determines whether a patient in a shockable rhythm survives, returned 79 papers. The ratio of post-arrival to pre-arrival research attention runs at roughly 10:1 to 20:1 depending on the keyword pair.

The clinical consequence of this imbalance is measurable. Each minute of delay to defibrillation in witnessed ventricular fibrillation costs 7–10% of absolute survival [5,21]. Bystander defibrillation before EMS arrival is associated with 53% 30-day survival for shockable rhythms; without it, 16% [7]. Public-access defibrillation programmes are cost-effective when AED density matches incident density, and demonstrably ineffective when retrieval distance exceeds a few hundred metres [2,36]. The 2015 Institute of Medicine review drew the conclusion explicitly: community response capacity is the under-invested link in the chain of survival [37].

The marginal-return case for correcting the skew

The marginal-return argument is straightforward. An extra dollar spent on eCPR protocols reaches patients who are already deep in a low-probability state; the effect size is small, and the downstream costs (ECMO, ICU days, neurorehabilitation) are large. An extra dollar spent on getting a working defibrillator to the patient within three minutes of collapse reaches patients whose survival odds are still high and drops the downstream cost curve at the same time. The 2015 IOM review put the same logic in policy terms: national survival will not move without investment in the pre-arrival links [37]; Callaway’s 2017 editorial called for targeted grant mechanisms to correct the skew rather than simply enlarging the pot [38].

Where drone-AED delivery fits

Drone-delivered defibrillation is best read as a corrective investment in this context. It does not displace in-hospital research; it addresses time-to-defibrillation in residential settings, where the survival gradient is steepest and the research spend has been thinnest. A pilot of the scale proposed here (two bases, AUD $2–3M) sits well inside the noise floor of the Australian cardiac-arrest research budget and targets the single intervention with the largest evidenced per-minute survival effect. The ask is not a new priority but a rebalancing toward the part of the chain the literature has, for structural reasons, left under-studied.

We propose a funded 12-month pilot to test whether the modelled performance holds under real operational conditions. The pilot runs as a three-site, three-tier deployment: one Metro site, one Regional site, one Rural site. This is a deliberate re-framing away from the earlier Greater-Sydney-only two-base plan. The rural-and-regional case is stronger on the arithmetic (slower ambulance response amplifies the drone-delivered survival lift), on the regulatory pathway (less contested airspace, lower SORA-AU ground-risk classification), on the transferability of international analogues (Zipline in Rwanda, Everdrone in peri-urban Gothenburg), and on the equity framing that a sponsor grant panel will prioritise.

Three proposed pilot sites

The three candidates are the top-ranked pilot locations from the model’s three-tier scoring run, which combines observed BHI ambulance activity, Category 1 response-time deficit against a tier-specific target, and the modelled demand allocation score:

• Metro — Campbelltown (Sydney). Ranks headline Sydney-metro across every weighting variant the model has run. Sydney-metro delivers the volume case: ambulance activity around 4,400 incidents per quarter in the SA3, Cat-1 response median in the ten-minute range, and the highest modelled incremental-lives contribution of the three tiers. Sets the baseline for the downstream scaled-deployment business case.
• Regional — Port Macquarie. Ranks headline Regional with ambulance activity around 1,500 incidents per quarter, Cat-1 response median approaching twelve minutes, a substantial older-resident share, and a tier-2 airspace environment that simplifies the initial CASA submission. Port Macquarie carries clinically meaningful OHCA volume without the controlled-airspace-complexity burden of Greater Sydney.
• Rural — Far West (Broken Hill). Ranks headline Rural with a Cat-1 response median in the eighteen-to-twenty-minute range — more than twice the Sydney-metro deficit. Per-event survival lift from a drone-delivered AED at 4-minute arrival is the largest of any site the model has evaluated. Volumes are lower (a few hundred incidents per quarter) but the per-event case is the most compelling in the country. Rural also anchors the equity argument that carries weight with MRFF, NHMRC, and NSW Rural Health.

Each site is proposed as a single-base deployment. The full ranked shortlist carries secondary candidates per tier (Mount Druitt and Penrith for Sydney; Lake Macquarie and Morisset for Newcastle metro; Wollongong proper for the Illawarra metro; Kiama-Shoalhaven and Albury for Regional; Bourke-Cobar-Coonamble for Rural). A follow-up wave after the pilot evidence lands would scale against those, stratified by whichever tier shows the strongest real-world operational fit.

Pilot requirements

The pilot requires integration with NSW Ambulance dispatch across all three sites. Drones must launch on the same 000 call that triggers paramedic response, not on a parallel research protocol. Without dispatch integration, arrival-time comparisons are meaningless. This is a non-negotiable design requirement and the single largest coordination challenge.

Estimated budget: ~$3–5M fully-loaded across the three sites [ESTIMATED, operating-loaded]. That covers drone hardware and maintenance at three sites, tier-varied CASA regulatory approval and ongoing compliance (Metro carries the highest cost here; Rural the lowest), operational staffing under the managed-BVLOS model from Chapter 10, insurance, community engagement at each site, and independent clinical evaluation. The tier-varied costs matter: Campbelltown’s Part 101 Operations Approval is the most intricate submission of the three; Broken Hill’s is the simplest. The per-site cost envelope is therefore not uniform, and the Chapter 09 fully-loaded bill of materials publishes the pessimistic / base / optimistic ranges that bracket the ~$3–5M headline.

The pilot operates under the phased model set out in Chapter 10: remotely-piloted managed BVLOS from day 1, under a CASA ReOC with a specific Operations Approval for medical-delivery BVLOS in the three bounded trial corridors. The autonomous-at-scale transition is not inside the 12-month pilot scope; it is part of the case the pilot evidence would support.

What the pilot validates

The pilot would validate three things across all three tiers, and a fourth question specifically per-tier.

1. Actual drone arrival time versus ambulance arrival time across a statistically meaningful number of dispatches per site, stratified by Remoteness Area tier.
2. Bystander retrieval success rate — what proportion of recipients collect the AED and attach it. This is the single largest uncertainty in the survival model, and a three-tier pilot measures whether retrieval rates differ between Metro, Regional, and Rural bystander populations.
3. Preliminary clinical outcomes, recognising that a 12-month sample from three bases will lack power for definitive survival analysis but can establish operational viability across tiers.
4. Per-tier cost-envelope discipline — the fully-loaded BOM in Chapter 09 publishes pessimistic / base / optimistic figures; the pilot converts those from feasibility-stage placeholders into contracted rates, with tier-varied cost-per-QALY output that informs the scaled-deployment case.

If the pilot fails to demonstrate a meaningful time advantage at any tier, or if bystander retrieval rates fall below usable thresholds, the programme stops at that tier. If it succeeds — possibly at one tier, possibly at two, possibly at all three — the data supports a tier-differentiated case for scaled deployment built on evidence from Australian conditions rather than extrapolation from international trials.

We are available for a working session to scope the pilot design with NSW Ambulance, CASA, NSW Rural Health, and clinical stakeholders.

Technical acronyms and terms used throughout this report. Terms specific to a single chapter are defined inline where they first appear; this glossary lists programme-wide terminology. Entries are grouped by domain and ordered A–Z within each group.

Clinical

AED — Automated External Defibrillator. A portable device that analyses cardiac rhythm and delivers a shock if a shockable rhythm (VF or pulseless VT) is detected. Designed for use by lay bystanders; voice prompts walk the operator through pad placement and shock delivery.

CPR — Cardiopulmonary resuscitation. Chest compressions, with or without rescue breaths, used to maintain circulation to the brain and heart during cardiac arrest. Bystander CPR before EMS arrival roughly doubles survival odds.

DSED — Double sequential external defibrillation. An in-hospital and advanced-care technique where two defibrillators deliver near-simultaneous shocks via two pad sets, studied as a second-line option for refractory VF. Outside the scope of the LIFT Study 01 pilot, listed here because it appears in the broader OHCA literature.

eCPR — Extracorporeal cardiopulmonary resuscitation. Venoarterial ECMO deployed during ongoing CPR to take over circulation while the underlying cause of arrest is treated. Hospital-based, resource-intensive, and restricted to a narrow eligible cohort.

mCPR — Mechanical cardiopulmonary resuscitation. Chest compressions delivered by a device (for example LUCAS or Autopulse) rather than by hand, typically used during transport or prolonged resuscitation.

OHCA — Out-of-hospital cardiac arrest. Sudden cessation of effective cardiac output occurring outside a hospital setting. Survival to discharge in Australia sits near 10–12%, heavily contingent on bystander CPR and time to first defibrillation.

ROSC — Return of spontaneous circulation. Restoration of a palpable pulse and measurable blood pressure after cardiac arrest, typically detected on rhythm check or carotid palpation. Pre-hospital ROSC is the first survival milestone but does not guarantee survival to discharge.

VF — Ventricular fibrillation. A chaotic, disorganised ventricular rhythm that produces no effective cardiac output. The most common initial shockable rhythm in sudden cardiac arrest and the one most responsive to early defibrillation.

VT — Ventricular tachycardia. A rapid ventricular rhythm which, when pulseless, is treated as a shockable arrest rhythm alongside VF.

Regulatory and operational

BVLOS — Beyond visual line of sight. A drone operation in which the remote pilot cannot see the aircraft directly. BVLOS is the operational mode any realistic AED-delivery network requires and is the main regulatory hurdle under CASA Part 101.

CASA Part 101 — Civil Aviation Safety Authority Part 101 Manual of Standards. The Australian regulation covering unmanned aircraft, model aircraft and rockets. Part 101 sets out the categories of operation, pilot qualifications, and the approval pathway for BVLOS flight [25].

IP55 — Ingress Protection rating 55 (IEC 60529). The first digit (5) indicates dust-protected (limited ingress, no harmful deposit); the second digit (5) indicates protection against low-pressure water jets from any direction. IP55 is the waterproofing threshold typically expected for outdoor drone operations in Sydney conditions.

Part 135 — CASA Part 135, the Australian regulation covering small-aeroplane air-transport operations. Cited in this report only as context for how crewed-aviation rule sets differ from the Part 101 unmanned framework.

Part 137 — CASA Part 137, the Australian regulation covering aerial application (agricultural) operations. Referenced for comparison with Part 101; sets a precedent for dispensing payloads from aircraft, though the AED-delivery use case sits squarely within Part 101.

ReOC — Remotely Piloted Aircraft Operator’s Certificate. The CASA-issued certification an organisation must hold to fly drones commercially in Australia under Part 101, including for BVLOS approvals.

SORA-AU — Specific Operations Risk Assessment, Australian adaptation. A structured risk-assessment methodology used by CASA to evaluate applications for complex drone operations (including BVLOS), adapted from the JARUS SORA framework used in Europe.

TGA — Therapeutic Goods Administration. The Australian government agency that regulates medical devices, including AEDs. Any device carried by the drone network that meets the clinical definition of a therapeutic good must be TGA-listed or TGA-registered before deployment.

Data and methodology

IRSAD — Index of Relative Socio-economic Advantage and Disadvantage. One of the four SEIFA indexes published by the ABS, summarising both advantage and disadvantage in a single distribution. Used for cross-checks against IRSD in this report’s sensitivity analyses.

IRSD — Index of Relative Socio-economic Disadvantage. The SEIFA index used as the primary socio-economic weight in the synthetic OHCA proxy; lower scores indicate greater relative disadvantage [20].

QALY — Quality-adjusted life year. A standard health-economic unit that combines length of life with a quality weight (0 = death, 1 = full health). Cost-per-QALY is the measure used in the cost-envelope chapter to compare the drone network against other public-health investments.

SA2 — Statistical Area Level 2, Australian Bureau of Statistics. A medium-sized general-purpose spatial unit (typically 3,000–25,000 residents) used as the primary geographic unit for the spatial analysis, demand signal, and coverage chapters.

SEIFA — Socio-Economic Indexes for Areas. The family of four ABS-published indexes (IRSD, IRSAD, Index of Education and Occupation, Index of Economic Resources) that summarise relative socio-economic conditions at a given geographic level.

TCO — Total cost of ownership. The five-year all-in cost figure used in the cost-envelope chapter: capital purchase, regulatory compliance, base infrastructure, maintenance, consumables, and training. Distinct from capital outlay alone.

Organisations

AHA — American Heart Association. US professional body whose resuscitation guidelines and science-gap audits are cited throughout this report [1].

AIHW — Australian Institute of Health and Welfare. Federal statistical agency for health and welfare data; source of the national OHCA burden estimates cited in the spatial-analysis and survival-impact chapters [3].

EMS — Emergency Medical Services. The umbrella term for pre-hospital emergency clinical response, delivered in New South Wales primarily by NSW Ambulance. The interval from collapse to EMS arrival is the key determinant of OHCA survival this report seeks to shrink.

GoodSAM — A volunteer-responder platform integrated with NSW Ambulance’s computer-aided dispatch. Alerts nearby trained bystanders (off-duty clinicians, verified community responders) to a suspected cardiac arrest and directs them to the nearest registered public-access AED [12,15].

NHF — National Heart Foundation of Australia. Non-government funder of cardiovascular research; cited in the research-spend-imbalance chapter as the smaller of the two main Australian funders of cardiac-arrest work.

NHMRC — National Health and Medical Research Council. Australia’s main federal funder of health and medical research; sets the national grant portfolio analysed in the research-spend-imbalance chapter.

NSW Ambulance — The statutory emergency ambulance service for New South Wales, a division of NSW Health. Operator of the computer-aided dispatch system, the VACAR-aligned registry feed for NSW, and the GoodSAM integration.

VACAR — Victorian Ambulance Cardiac Arrest Registry. The long-running Victorian OHCA registry whose published survival trends and epidemiological denominators are used as the closest Australian benchmark for this report [11].