By the time an ambulance got to Johnathon Taituma, 43, about an hour and 40 minutes after his initial 111 call, he was dead. Photo: RNZ / Kim Baker Wilson

Johnathon Taituma called 111 struggling to breathe.

But by the time an ambulance got to the 43-year-old, about an hour and 40 minutes later, he was dead after what a coroner said was a cascade of errors.

It was not just Taituma who called for help.

His neighbour did too after he went to her for help still struggling to breathe.

Both times a wrong priority was recorded.

Now, an associate coroner has urged St John audit itself to see if the delay was an aberration of care, or if they were happening in other cases as well.

They had also referred the botched callout to the Health and Disability Commissioner.

St John said an audit was underway along with several other steps, and said it was deeply sorry and that it had committed to change when it fell short.

Two weeks before Christmas in 2024, Johnathon Taituma rang 111 from his Manurewa address - he said he was alone and having trouble breathing.

He was assigned an 'ORANGE2' priority, a level Associate Coroner James Buckle said was wrong.

It should have been 'RED2' and would have meant an ambulance would have arrived an estimated five minutes after dispatch.

But there was no dispatch, and no ambulance was assigned.

Taituma made his 111 call at 4.35pm.

About nine minutes later he went to his neighbour's back door repeatedly hitting his chest, struggling to breathe and trying to take in large amounts of air.

He asked the neighbour to call an ambulance and told her he had already called one and had collapsed.

At about 4.47pm the neighbour made the call and it was identified that Taituma had earlier called himself and collapsed and that he was still struggling to breathe.

His case was not re-triaged, and he remained on the ORANGE2 priority.

Associate Coroner Buckle said the neighbour's information showed Taituma deteriorated since his earlier call and he should have been re-triaged.

If that had happened, he said, he would have been given a RED priority in the least.

An orange priority is for a callout that appeared serious but not life-threatening, with an ambulance sent as soon as possible at normal speed.

A red priority is for something immediately life-threatening, with an ambulance or ambulances dispatched straight away under lights and siren.

When Taituma made his call he was told help was being arranged.

His neighbour was told the same, but the associate coroner said this was wrong.

"As with the first phone call, Initial Assign was not launched and an ambulance was not dispatched," they said in findings released on Tuesday.

Taituma and his neighbour stayed together for 10-20 minutes.

He got up and walked home.

Standard St John operating procedures required welfare checks every 30 minutes "on all active emergency ambulance incidents".

If there is no contact, then time is re-set to five minutes.

If three consecutive welfare checks are unsuccessful, the case is escalated to a a Clinical Support Officer.

The associate coroner said three attempts were made to contact Taituma, the first some 51 minutes after he called 111.

Another was 39 minutes after the neighbour's own 111 call.

No contact was made with Taituma on the first call and follow-up calls, while timely, were made outside the five-minute timeframe.

There was no evidence suggesting St John tried to contact the neighbour, Buckle said.

There was also no evidence the case was sent up to a Clinical Support Officer.

An ambulance was dispatched at 6.05pm.

At 6.15pm, the neighbour went to Taituma's home and found him lying face down in the living room.

She looked for a pulse and rang 111 again three minutes later.

Ambulance staff reached him by 6.22, he was not breathing and had no pulse.

The crew could not resuscitate him.

It would later be found he died from an acute coronary embolus.

St John says a review of call-handling errors resulting in adverse events of a year-long period found a "trend of errors". Photo: 123rf

The coroner could not say what the chances of Taituma surviving were if crews had turned up sooner to treat him with electric shock.

"Therefore, I cannot be satisfied that the cascade of errors by Hato Hone St John caused Mr Taituma's death," Associate Coroner Buckle said.

"Neither can I be satisfied that they contributed to his death."

The associate coroner said despite this, it was appropriate he made recommendations to reduce the chances of further deaths.

"This is because the chances of survival in cases of heart attacks are significantly increased by the timely attendance of, and treatment by, ambulance staff and dealing with the errors that arose in Mr Taituma's case will increase the chances of timely attendance and treatment," he said.

The associate coroner asked St John what remedial action had been taken, if any.

It replied a review of call-handling errors resulting in adverse events of a year-long period found a "trend of errors".

This was in the management of subsequent calls and welfare checks, it said.

"Subsequently, there is ongoing consideration of recommendations to minimise these errors in the future," St John told the Associate Coroner.

"Additionally, new educational platforms have been introduced imbed [sic] learnings from reviews for continued professional development."

The associate coroner said they were satisfied St John was moving to avoid a repeat.

"However, I also have concerns about the welfare checks made by Hato Hone St John," Buckle said in his findings.

"A welfare check was made by calling Mr Taituma approximately 51 minutes after he first rung Hato Hone St John."

The call was made 30 minutes after the neighbour's first phone call, he said, noting it was outside of the 30-minute timeframe in St John's procedures.

"This could be explained by staff dealing with other calls and not being available in the mandated 30-minute timeframe, which would be an understandable and reasonable explanation," the associate coroner said.

"However, the purpose of the calls seems to be to contact either the patient or someone that can speak for the patient … the welfare calls that were made do not seem to have fulfilled their purpose."

The associate coroner recommended St John audit its welfare check phone calls with a view to finding out whether the delay in calling Taituma back was an aberration or whether there were delays in other cases.

They also said the audit should determine if the current system was fulfilling its purpose.

"If Hato Hone St John establishes that there are systemic issues causing delays in contacting patients then they should identify those systemic issues and rectify them," the associate coroner said.

The associate coroner said there was an arguable case St John breached the Code of Health and Disability Consumer's Rights by not giving Taituma "an appropriate standard of care".

"In the circumstances I am satisfied that it is appropriate to refer the matter to the Health and Disability Commissioner," he said.

St John told RNZ it extended sincere condolences to Taituma's whānau and that it would address any systemic issues found.

"When we fall short, we are committed to learning, improving, and making necessary changes to better support our patients and communities," John-Michael Swannix said, St John's integrated operations manager for primary triage and dispatch.

"We reiterate how deeply sorry we are to Mr Taituma's family and acknowledge the neighbour who tried to help. We remain committed to improving our processes so people across Aotearoa can continue to trust the care they receive when they call for help."

Swannix said St John accepted the Associate Coroner's findings and recommendations.

It said it had undertaken a number of steps:

St John said it was auditing welfare checks to see if delays in Taituma's case were isolated or systemic, in line with the associate coroner's recommendations.

This would also look at whether current processes were effective.

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