Photo: Supplied / St John Ambulance
When Margaret Wells' husband called emergency services saying his wife was having a heart attack, it took over an hour for the ambulance to arrive. By that time Wells was unresponsive.
About 30 minutes later, she was dead.
In recently released findings, Coroner Mary-Anne Borrowdale slammed Hato Hone St John's decision to send its available ambulance to a less urgent incident rather than directly to Wells "within time to attempt to save her life when she went into cardiac arrest".
"Mr and Mrs Wells were elderly and alone, and Mr Wells was a double-amputee who was unable to effectively aid Mrs Wells in her medical emergency. They were each entitled to expect a quicker response from St John," the coroner said.
In her decision, Borrowdale detailed the events leading up to 78-year-old Margaret (Margot) Wells' death on 20 September, 2020, at the home she shared with her husband of 57 years, Alfred, in Ashley, near Rangiora in North Canterbury.
Wells lived with her husband of 57 years, Alfred.
About 2.45am on a Sunday, Wells woke Alfred and asked him to call an ambulance. She had vomited, was pale and sweating, and experiencing chest pains.
Her husband called 111 five minutes later and said his wife was having a heart attack. "She is just lying there - doesn't look very good at all," he said.
The call handler said she was organising help and if Margot became more unwell, Alfred should call 111 back.
By 3.40am no ambulance had arrived and Alfred called 111 again. He was agitated and said his wife's condition had worsened. "I don't think she is breathing."
The call handler began giving Wells resuscitation instructions, telling him to put his wife on the floor. Wells said he was a double amputee and unable to lift her, but he eventually managed to get her on the floor. The call handler then explained how to give CPR.
When an ambulance crew arrived at 3.46am, they found Alfred Wells giving ineffective CPR to his wife who was unconscious and not breathing. The crew took over and tried to revive Margot, but to no avail. She was pronounced dead at 4.20am.
An autopsy confirmed she died from a heart attack.
A coronial inquiry into her death scrutinised St John's actions and its failure to respond in a more timely manner to Alfred's first 111 call.
According to evidence by St John's clinical director, Dr Tony Smith, Aldred's first call was categorised as "red", the second-highest priority. Smith said this was the correct categorisation as by that point Wells' heart had not stopped. The highest priority, purple, is reserved for patients whose heart has stopped beating.
When Alfred called at 2.50am, St John had 11 crewed ambulances in Canterbury and all were already responding to incidents.
One ambulance was attending a lower-priority incident, but was not reassigned to attend to Wells' higher priority call. Another ambulance that was assigned to Aldred's call did not respond as no volunteers were rostered that night.
By 2.57am, a third ambulance was assigned to Wells, but was then reassigned to a higher priority "purple" event elsewhere.
By 3.27am, another ambulance was assigned and the crew arrived 19 minutes later.
The coroner heard it was "an almost daily occurrence" in Christchurch for St John to have more emergencies to attend than it has crewed ambulances. The service often couldn't reach its target for responding to "red" incidents.
"The public health risk that arises from such an overstretched ambulance service is obvious," the coroner said.
Not only should an ambulance have been dispatched to Wells immediately, St John should have made a welfare call to Alfred when the ambulance was delayed, she said. It may not have changed the outcome, but Alfred's "distress and uncertainty may have been somewhat alleviated".
The coroner accepted St John's delayed response contributed to, but did not cause Margot's death.
Despite the fact she died of natural causes, the circumstances were "deeply troubling".
The coroner recommended St John expand its questions to gather information about whether the caller has any impediment that would prevent them from assisting a patient while help was on the way. Priority should also be increased when the patient could not get essential assistance from the caller or others present, she said.
The Press has approached Hato Hone St John for comment.
This story was first published by The Press.