When Johnathon Taituma was struggling to breathe, he called 111 for help - but a St John call taker gave him the wrong priority code, which meant an ambulance was not sent. 

As his condition deteriorated, the 43-year-old Auckland man went to a neighbour who also called 111, but again the wrong code was entered. 

An hour and a half later, his neighbour found him unconscious and called 111 again - but by the time St John arrived it was too late. 

Now, a coroner has found there is a possibility Taituma may have survived if it weren’t for Hato Hone St John’s “cascade of errors”. 

According to findings released today, Taituma called 111 on December 11, 2024 saying he was alone and having trouble breathing. 

He was put through to Hato Hone St John and asked a series of questions and then assigned a code, called a determinant, which was the priority level assigned to him. 

His assigned code was “orange”, which indicates the incident appeared serious but was not immediately life-threatening. He should have been assigned a “red” code, which would have sent multiple ambulances immediately. 

Because he was given the wrong code no ambulance was assigned to him, nor was he placed in a queue for one. 

Ten minutes later Taituma was struggling to breathe as he spoke to his neighbour and was repeatedly hitting his chest while trying to take in large amounts of air. 

His neighbour explained his condition had deteriorated but the call taker did not re-triage Taituma, and he remained at priority orange. 

He returned to his own home soon after. 

One hour and 20 minutes later, Taituma’s neighbour noticed the ambulance hadn’t arrived so she went to check on him. 

She found him lying face down on the floor and called 111 again saying “I was just wondering if this fella is alive now because now, he’s on the floor and he has hard breathing”. 

Ambulance staff were just arriving and tried to resuscitate Taituma, but he died at the scene. 

Cascade of errors 

Now, associate coroner James Buckle has found that if an ambulance had attended when Taituma first called, it’s possible that he could have been treated in time to save his life. 

“If Mr Taituma had been assigned an ambulance to attend on him immediately and it had arrived prior to or at about the time of the second call then any cardiac arrhythmia would have been promptly detected. It is likely that Mr Taituma would have shown signs of myocardial ischaemia and would have been treated,” Buckle said. 

“…if Mr Taituma’s cardiac issues were of the kind that is amenable to treatment by electric shock, which is the most likely scenario, and an ambulance had arrived at his home promptly, then his likelihood of survival was probably in the range of 23 to 55%." 

However, there was a chance that Taituma was suffering a heart attack that wouldn’t have responded to defibrillation by paramedics. 

Because of this, Buckle said he couldn’t make a finding that Hato Hone St John caused Taituma’s death, nor that its response contributed to it. 

“I am not able to comment on the likelihood of Mr Taituma surviving if his cardiac issues were of a type that are not amenable to treatment by electric shock. 

“An acute coronary embolus can be fatal. Even with the most optimistic view of the statistics there is no guarantee that Mr Taituma would have survived if an ambulance had reached him quickly and he had been given the appropriate medical care. 

“Therefore, I cannot be satisfied that the cascade of errors by Hato Hone St John caused Mr Taituma’s death. Neither can I be satisfied that they contributed to his death.” 

Hato Hone St John told the associate coroner that coaching had since been provided to its staff, and an internal review found that there had been a “trend of errors” in its management of welfare checks on patients waiting for ambulances. 

Based on that review, the ambulance service said it was rolling out an update to its standard operating procedures. 

Buckle recommended Hato Hone St John audit its welfare check system to establish if Taituma’s case was an aberration or if the delay had been happening in other cases. 

“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,” he said. 

Buckle also referred the case to the Health and Disability Commissioner. 

NZME reported last year that the Health and Disability Commissioner received 166 complaints involving Hato Hone St John from July 1, 2019, to June 30, 2024. 

They included two cases where people died because of delays in the arrival of ambulance crews. 

In 2022 Barbara Rose McGee called for an ambulance after struggling to breathe early on Christmas Eve. When ambulance crew arrived more than four hours later they found her dead in her bed. 

Coroner Erin Woolley said last year that McGee’s initial 111 call was incorrectly coded, and that standard procedure around welfare checks was not followed. 

Hato Hone St John’s integrated operations manager, John-Michael Swannix, said that the organisation extended its condolences to Taituma’s family for their loss. 

“In line with the coroner’s recommendations, we are auditing welfare checks to assess whether the delays seen in this case are isolated or systemic and whether current processes are effective. This will include reviewing when and how third parties are contacted when patients cannot be reached. Any systemic issues identified will be addressed,” Swannix said. 

“Every 111 call reflects someone in need of help, and Hato Hone St John takes our responsibility to respond safely, promptly, and appropriately very seriously. When we fall short, we are committed to learning, improving, and making necessary changes to better support our patients and communities. 

“We reiterate how deeply sorry we are to Mr Taituma’s family and acknowledge the neighbour who tried to help.” 

Jeremy Wilkinson is an Open Justice reporter based in Manawatū, covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.