A man who cut his arm badly at a building site died after being rushed to hospital in a work van, when an ambulance took too long to arrive.

The 43-year-old had been removing rubbish from the site when a plate glass window he picked up shattered and cut his right arm at the elbow.

Despite frantic 111 calls from the man’s son, who saw what happened, and from another person on the site, a relief dispatcher put the first ambulance that became available on a rest break.

The second was sent to a less serious incident, a report by the Health and Disability Commissioner (HDC) has found.

When an ambulance did arrive, more than half an hour after the first call, the crew discovered the man had been taken to hospital.

The man’s son had tied his father’s arm in a T-shirt as tightly as he could, lifted him up and loaded him in the work van before rushing him to hospital.

A man rushed to hospital by his son died from blood loss soon after arriving, despite efforts by a hospital emergency team to save him. Hato Hone St John has been heavily criticised by the Health and Disability Commissioner for failures that led to delays in sending an ambulance. Photo / 123rf

Despite the emergency response by hospital staff and prolonged attempts at resuscitation, the man died from blood loss.

‘String of failures’

Now, Hato Hone St John Ambulance has been heavily criticised for what the HDC said was a string of failures leading to the delay in sending an ambulance, including the way in which multiple staff handled the calls and dispatch.

Consequently, St John was found to have breached a section of the Code of Health and Disability Services Consumers’ Rights for failing to provide services to the man, named as Mr A, with reasonable care and skill, Commissioner Morag McDowell said in her report, released today.

This was because of its “inadequate policies and a lack of staff understanding of the policies”, which resulted in the individual errors by staff, she said.

McDowell said there were also many missed chances to escalate the calls for urgent review, and confusion and inconsistency in the Patient Safety Incident (PSI) review created difficulty in assessing the care provided to the man.

She said the errors identified with the call-handling represented an organisational failing for which St John was responsible, rather than isolated individual errors.

“I consider that this highlights a need for St John to review the training and support provided to its staff in this area.”

St John accepted the finding and the recommendations, adding that the 2021 incident happened during the Covid-19 pandemic, when resources were stretched.

Acting head of clinical governance Cheryl des Landes told NZME that on behalf of the organisation, she extended its deepest condolences to Mr A’s family for their loss and offered its sincerest apology.

St John told the HDC that about 70 dispatch handovers occurred per shift and, while highly adverse incidents were rare during this complex and high-risk period of the dispatch process, it accepted there was room for improvement.

Today’s finding comes after NZME reported in January this year that the HDC had received 166 complaints involving Hato Hone St John from July 1, 2019, to June 30, 2024.

Health and Disability Commissioner Morag McDowell said an "organisational failing" was behind delays over sending an ambulance, for which St John was responsible. Photo / HDC

It followed coverage in 2024 of how a man experiencing “classic heart attack symptoms” died as his wife drove him to hospital after St John had still not dispatched an ambulance almost an hour after she made the first 111 call for help.

In July this year, NZME reported how a man who tripped and fell off the side of a driveway lay dying in front of family and friends, who tried valiantly to save him during the 45 minutes it took for an ambulance to arrive.

St John was criticised again after a woman struggling to breathe early on Christmas Eve called for an ambulance, but died before one arrived more than four hours later.

Serious bleeding from ‘dangerous injury’

McDowell, a former coroner and Crown prosecutor, said in the case involving Mr A, the two separate 111 calls were made about 30 seconds apart.

Handlers used software-guided assessment to determine the nature and severity of the bleeding and to provide advice while an ambulance was being arranged.

The two calls were merged in the system and met the criteria for the immediate dispatch of an ambulance, McDowell said.

Initially, no ambulances were available for dispatching, so the call was added to a “pending queue” while waiting for one to become available.

The man’s son explained in the first 111 call that his father was awake but in pain, and there was “serious bleeding” from what he described as a “dangerous injury”.

Instructions on controlling the bleeding were provided.

The call was sent to the dispatch queue to wait for an available ambulance.

The call was coded serious, but not immediately life-threatening.

A review later found the initial 111 call was only partially compliant with St John’s procedures.

The second 111 call was also non-compliant because of several errors with the call-handling process, which contributed to the failure to identify the seriousness of the incident, McDowell said.

The call taker later told the HDC that the job would “stay with her” and that she was truly, deeply sorry to the man’s family.

No ambulance available

The two calls were merged and re-triaged as an Orange 1 response, meaning immediate dispatch of an ambulance, but none were initially available.

The PSI review noted that although it was coded as such, there were no obvious notes in the incident report that alerted the dispatchers to the uncontrolled nature of the bleeding, and therefore the need for an ambulance to be dispatched immediately.

When the first became available at 3.57pm, the relief dispatcher on duty, and using the information at hand, put this ambulance on a rest break.

McDowell said this was an error in judgment and constituted an adverse event, as it should have been dispatched immediately after becoming available.

St John noted that another ambulance became available at 4.03pm, which was dispatched to another lower acuity incident.

It said a staff handover during a meal break contributed to the reduced awareness of a high-priority incident.

St John said that since the incident, it had made improvements to its dispatch and call-handling training and systems.

“This includes ensuring high-priority incidents are routinely reviewed and escalated to a clinician for secondary triage and upgrade where appropriate.”

Des Landes said it had also updated the processes for conducting welfare checks, supported by a real-time dashboard that helped identify when a welfare check for a patient was due.

“We remain committed to ensuring that our patients receive timely emergency care and will review the recommendations for additional opportunities to further strengthen our systems and processes,” she said.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.