Ambulance officers and Fire Service personnel have been criticised for the delay in properly treating a 35-year-old man as he lay dying of a heart attack at Wellington airport.
Up to 25 airport staff also failed Trevor William Morris, including several who witnessed his initial collapse but made no efforts to help save his life, coroner Gary Evans said in findings released yesterday.
"The attempted resuscitation of Trevor Morris fell well short of effective practice.
"There is little doubt that Mr Morris was not given the best possible chance of surviving his cardiac arrest due to delay in effective CPR and defibrillation."
Mr Morris' death on August 17, 2009, has prompted recommendations for all New Zealand airports, including supplying extra public access to defibrillators and providing CPR training for staff.
"Given four airport staff members were on the scene prior to the arrival of fire staff, CPR should have been commenced immediately, pending the arrival of fire staff with an AED (automated external defibrillator) machine," the coroner said.
Airport personnel also allowed passengers, including children, to walk "within touching distance" past Mr Morris, a fleet service manager from Carterton, as attempts were made to revive him.
The report recommends crowd control training for all airport staff and making screens available to protect such scenes.
A spokesman for Wellington Airport said all the coroner's recommendations had been implemented.
The acting chief executive of Wellington Free Ambulance, Andy Long, said the service "deeply regrets the tragic death" of Mr Morris.
"The way we handled this incident was not satisfactory and we deeply regret the resulting tragedy and the impact on Mr Morris and his family," Mr Long said.
There was an 11-minute delay for the ambulance to reach the scene, the coroner found.
As well as failing to continue CPR and effectively provide defibrillation, "there were too many attempts at intubation which interrupted the chest compressions", the report said.
"There was poor co-ordination of the resuscitation and no one clear team leader."
Mr Long said Mr Morris' death had prompted training of paramedics to be "reviewed and strengthened" to "ensure the events that led to this outcome are not repeated".
Data from each cardiac arrest attended by paramedics is analysed down to the timing of each chest compression and feedback is provided to improve their performance.
Airport Fire Service staff must complete an eight-hour "refresher course", including changes to CPR procedures, each year. They are also trained to use defibrillators and practise realistic scenarios.
CCTV footage of Mr Morris' collapse and treatment at the airport was used by Fire Service staff to learn how to "better understand patient treatment, leadership and scene control".
Airport Fire Service manager John Barnden said it was "clearly identified that a number of things could or should have been better dealt with at the time of Mr Morris' treatment".
Mr Evans said the changes and improvements made by the airport were to be commended.
Mr Morris was pronounced dead at Wellington Hospital after 32 minutes were spent trying to revive him in the airport.
Mr Morris' partner Linda Sage said it was "very traumatic" to relive the incident with the release of the coroner's findings and she "certainly" hoped lessons had been learned from the shortcomings in Mr Morris' treatment.