A man experiencing “classic heart attack symptoms” died as his wife drove him to hospital after Hato Hone St John had still not dispatched an ambulance almost an hour after she made the first 111 call for help.

The woman’s decision to make the 15-minute drive herself came after her husband’s condition deteriorated and during a second call to 111 she was told an ambulance was yet to be assigned.

Three minutes from the hospital, he suffered a cardiac arrest and could not be revived by Emergency Department staff.

Following the man’s death in 2020, his wife complained to Hato Hone St John, and the Nationwide Health and Disability Advocacy Service made a complaint to the Office of the Health and Disability Commissioner (HDC) on her behalf.

HDC deputy Deborah James has since investigated the incident and found Hato Hone St John, and a call handler, breached the man’s rights under the Code of Health and Disability Services Consumers’ Rights.

It comes months after the HDC breached an ambulance call taker who incorrectly classified and recorded triage information relating to a Tauranga teen suffering an asthma attack. The error affected the subsequent dispatch of an ambulance and the teen died.

Hato Hone St John told NZME it accepted the HDC’s findings relating to the man’s death, which were released today.

“We apologise unreservedly to the patient’s wife and their family for failing to deliver the appropriate standard of care and for the distress this may have caused,” it said in a statement.

In the findings, which do not name the man or his wife, James detailed the management of the 111 calls.

She said an ambulance service took the woman’s initial call at 6.08pm and prioritised the job as “serious but not immediately life-threatening”.

The woman described him as having “quite bad” chest pain on his left side, pins and needles down his arms and being very red in the face.

Deputy Health and Disability Commissioner Deborah James investigated the incident. Photo / Supplied

The patient information and response priority code were then sent to the Hato Hone St John dispatch queue at 6.11pm.

About 6.55pm, a Hato Hone St John dispatcher launched an initial assignment tool to identify which ambulances were available.

The tool indicated a 27-minute wait for an ambulance and suggested using a Fire and Emergency NZ first response team, which was available. But the dispatcher decided this was unnecessary as the man was alert, breathing easily and had no cardiac history.

At 6.58pm, the woman phoned 111 again because her husband’s condition was “getting worse”.

Another call handler picked up and advised her an ambulance had not been assigned because of demand.

Despite the man’s wife telling the call handler her husband’s condition had worsened, the call handler did not ask for any further information about his symptoms and did not re-triage the call.

The woman told the call handler she would drive her husband to the hospital, saying she thought “that would be best”.

At 7pm, the call handler closed the incident, marking it as no longer needing an ambulance response.

On the way to the hospital, the man suffered a cardiac arrest and could not be revived.

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During the investigation, the woman told the HDC she believed the ambulance system was flawed.

“Why could they not have rung back as soon as they knew there was no ambulance immediately available for dispatch,” she asked.

“Why would they wait for such a long time to do what they called a ‘welfare check’ when they knew there was no ambulance available … I know that there is a defibrillator available just down the road … which is operated by a voluntary fire service — could they not have been called until an ambulance was available?

“I guess believing that by getting help as soon as possible after the onset of cardiac symptoms doesn’t always save someone unless the service is reasonably easily accessible, which I believed [it] would have been.”

In her findings, James found the second call handler had deviated from Hato Hone St John’s standard operating procedure (SOP).

“The St John incident review identified that when [the woman] advised [the call handler] that she would take [the man] to hospital herself, there was a need for [the call handler] to advise that it might be a good idea to continue waiting for the ambulance response.

“I note that [the call handler’s] failure to re-triage [the woman’s] second 111 call may have affected her decision not to advise [the woman] to wait for the ambulance to arrive.”

In finding the call handler breached the Code by not providing services that complied with professional standards, James noted her failure to ask for further information about the man’s worsening symptoms.

She recommended the call handler formally apologise to the woman.

James found Hato Hone St John had also failed the man by not meeting expected wait times when there was a 30-minute delay in using the initial assignment tool, nor was a welfare check undertaken.

“There will undoubtedly be times when ambulances are unavailable to respond to incidents immediately. However, it is St John’s responsibility to find ways to mitigate the risks associated with unavailable ambulances.

“In my view, conducting welfare checks every 30 minutes (as outlined in St John’s SOP) is an appropriate tool in mitigating such risk.”

She found Hato Hone St John breached the code by not providing the man, through his wife, with information he could have expected to receive under the circumstances. This included not conducting a welfare check and not advising the woman about delays in dispatching an ambulance, or for her to wait for an ambulance response.

An adverse comment was also made in the findings about the Hato Hone St John dispatcher who launched the initial assignment tool.

James noted her concerns about the delay, stating it was a useful safety netting tool that should have been deployed.

Further recommendations include that Hato Hone St John provide additional training for call handling and dispatch staff on the importance of welfare checks, and to update its dispatching guides to be clearer about how to use the initial assignment tool.

The findings stated it had made a range of changes in response to the incident.

Hato Hone St John told NZME it was always looking at ways to improve its systems and guidelines to ensure it provides patients with the best level of care it can.

“We are currently working our way through the Commissioner’s final recommendations, and we are committed to learning from the report’s findings.”

Tara Shaskey joined NZME in 2022 as a news director and Open Justice reporter. She has been a reporter since 2014 and previously worked at Stuff covering crime and justice, arts and entertainment, and Māori issues.