A meeting in an emergency communications centre got in the way of getting an ambulance to a fatal house fire.
This came after a glitch in the outdated and patchy 111 emergency call system.
The delay was revealed in documents Fire and Emergency released to RNZ about the response to a fire in the Auckland suburb of Hillpark on 13 May, which killed two men and seriously injured another.
The 111 call came through to FENZ call takers in a northern emergency comms centre they share with police, and they sent on the alert to the ambulance service.
But the system is fragmented, and the channel that connects it, called InterCAD, suffers random outages, which increased markedly from 2021 to early 2024.
The 111 call did not go through.
At the fire end, the comms staff did not immediately realise the system had broken, according to the FENZ summary of the debrief provided to RNZ under the Official Information Act.
"The shift manager was out of the room in a meeting at the time," the northern communications centre manager told the national manager of communication centres, who was looking into what happened following a "hot debrief".
"When it was seen that the message via InterCAD has not gone to the ambulance successfully, a phone call was made to their operators."
This added an unspecified amount of time to the ambulance response. RNZ has asked FENZ to specify the timings.
"The shift manager debriefed the watch and highlighted the importance of checking to make sure that these notifications go through, ensuring the whole watch was aware of this," it said.
Comms centre staff have spoken about how the outdated system adds to their stress.
Official documents show increasing problems with fire or police alerts failing to get through to ambulance's separate alert system; the InterCAD system had 39 problems last year, up from just six in 2021.
Police told RNZ last month they made repairs in March that had reduced the outages. A further change was made after the Hillpark fire.
"As part of the watch debrief, it was suggested that the error message communicating the failure to send an incident via InterCAD be highlighted green so it would stand out to the dispatcher," FENZ told RNZ.
Everyone agreed this was a good idea, and a green error message has been added since 21 May, the summary said.
"It is Fire and Emergency's view that no additional work is required in this area," FENZ said.
"The review demonstrated effective hot debrief actions and resulted in a change that improves service delivery."
However, the police-and-fire CARD system that supports 111 calling remains old and inflexible, and separated from ambulance. The services have repeatedly patched it up, but no replacement is in sight.
A project to introduce a modern integrated system across all three services - and one that can take not just phone calls but texts and video - failed to get funded in Budget 2023, and the previous government pushed it on to the new one, where it remains in limbo.
What it would cost has been blanked out of OIA papers.