By Tracy Neal. Open Justice multimedia journalist of 
Photo: ST JOHN NZ
A woman struggling to breathe early on Christmas Eve called for an ambulance, but died before one arrived more than four hours later.
An ambulance crew arrived at Barbara Rose McGee's Auckland home around 7am and found her dead in her bed.
It was the third unit dispatched to help McGee that morning in 2022, after the first two were diverted to higher-priority calls.
A coroner found that the 67-year-old, who suffered from emphysema, died from a type of pneumonia known as acute bronchopneumonia, which caused inflammation to her airways and lungs.
Two months earlier, a man lay dying in front of family and friends who tried in vain to save him during the 45 minutes it took for an ambulance to arrive.
NZME reported in January this year that the Health and Disability Commissioner had received 166 complaints involving Hato Hone St John from 1 July 2019 to 30 June 2024.
They included two cases where people died because of delays in the arrival of ambulance crews.
A coroner has again pointed to failures in the ambulance call-taker process.
In her recent findings, Coroner Erin Woolley said that McGee's initial 111 call was incorrectly coded, and that standard procedure around welfare checks was not followed.
Hato Hone St John deputy chief executive of clinical services, Damian Tomic, told NZME it apologised unreservedly for what happened, and had extended condolences to McGee's whānau, whom the service had offered to meet.
Call for help that arrived too late
According to the findings, McGee experienced difficulty breathing early on 24 December 2022.
Her son had visited the day before and made her comfortable after she messaged to say she had the "flu and a fever" and was "very weak and sleepy".
Around 3am, McGee phoned 111 and asked for an ambulance.
She had also tried to reach her son by text message to say she was going to the hospital and that she could not breathe.
Her son woke to the messages at 6am. He was told by the police of his mother's death when he later arrived at her house.
When McGee called the ambulance, she told the call taker she had been unwell for a while and was experiencing shortness of breath.
The call was coded as an "orange" response, which meant it was considered serious, but not immediately life-threatening.
An ambulance was sent about 15 minutes later but was then reassigned to attend a call coded as "an immediate life-threatening situation".
At 4.20am, an emergency call handler phoned McGee to conduct a welfare check.
Coroner Woolley said the notes from this call indicated there had been no change in her condition.
A further welfare call was made at 5.30am, but McGee was unable to be reached.
A second ambulance was sent an hour later, but that too was reassigned to a higher priority call.
A third ambulance was sent to McGee's address just before 7am.
It arrived 10 minutes later, but McGee was dead. .
Procedures 'not correctly followed'
Coroner Woolley found that welfare calls should have been made every 30 minutes until emergency services arrived.
When McGee could not be reached, further attempts should have been made to contact her, and if there was still no response, then a reassessment would have been required.
"On this basis, it appears that in addition to Barbara's initial call being incorrectly coded, the standard operating procedure about welfare checks was also not correctly followed," the coroner said.
St John investigated its response and found that the call handler had incorrectly recorded McGee's answer to a question about her breathing.
The handler asked McGee if she had difficulty speaking between breaths, and recorded "no", but a review of the call found McGee could clearly be heard struggling to breathe.
Coroner Woolley said the answer should have been recorded as "yes".
"Had Barbara's answer been correctly recorded, her call would have been coded as a 'red' priority/immediately life-threatening situation, requiring the immediate dispatch of an ambulance."
St John told the coroner that it would have provided further training to the relevant call-taker; however, that person had resigned after what happened.
One of the improvements the service identified was the possibility of creating a process to address the situation when no voice contact was established during a welfare call.
It also proposed changes to the line of questioning and the terminology used for these call-backs, currently referred to as "welfare checks", to make them more safety-focused.
Coroner Woolley recommended that St John ensure all call-takers were reminded of procedures around welfare checks, and that if contact could not be made, attempts must be made every five minutes and a reassessment done.
St John told NZME it accepted the coroner's findings and recommendations.
"Patient safety is a core priority, and we've made significant improvements to how welfare checks are conducted," Tomic said.
He said they included more timely follow-ups and changes to the way checks were structured and phrased to ensure they were clear, consistent and safety-focused.
* This story originally appeared in the New Zealand Herald.
