Simon, who had two children aged 4 and 2, worked a night shift on January 28 returning home early the next morning and went to sleep at 10am.
After she woke mid-afternoon she went to have a shower and told her husband she felt dizzy and had chest pains. That evening she had a cardiac arrest.
Her husband began CPR and called for an ambulance at 6.53pm but one did not arrive at their Nawton address until 7.21pm.
A second ambulance arrived at 7.39pm and Simon was given adrenalin, shocked and taken to Waikato Hospital.
There she was intubated and taken to ICU but was not responsive and continued to deteriorate, dying the next day at 11am.
Dunn said an angiogram was unable to determine the cause of the cardiac arrest and there were no medical records to indicate why Simon would suffer a heart attack.
She had no history of cardiovascular disease but the pathologist who conducted her autopsy told the coroner Simon’s death was most likely related to an underlying weakness in her coronary arteries.
Her death was referred to the Cardiac Inherited Disease Group.
Dunn said the pathologist found no evidence to suggest Simon’s vaccination contributed in any way to her death and the Centre for Adverse Reaction Monitoring came to the same conclusion.
Simon’s husband Manoj Jose raised concerns with the coroner over the delayed response by St John to his emergency call.
St John provided a report showing it received the 111 call at 6.53pm, but an ambulance was not sent for seven minutes and when it was, it was sent from Morrinsville, a 30-minute drive from Hamilton and on the opposite side of the city from where Simon lived.
Between 6.53pm and 7.21pm when the ambulance arrived, four more calls were made to St John asking when the ambulance would arrive, including a second call at 7.05pm.
St John accepted it made several errors that evening including that the 111 call was not properly re-triaged after the ambulance service was advised Simon was not fully responsive, Dunn said.
“Had the St John service re-triaged that call correctly it was possible the ambulance may have arrived at the address nine minutes earlier.”
Secondly, other ambulances were available to respond to the 111 call but were not dispatched, Dunn said.
Had those services been dispatched an intensive care paramedic, who arrived with the second ambulance at 7.39pm, could have got to Simon within 13 minutes of the 111 call, Dunn said.
This would have placed the specialist paramedic with Simon at around 7.05pm, right when the second call was being made to find out how long an ambulance would be.
“It is regrettable and unsatisfactory that there was a delay in the ambulance arriving at the address,” Dunn said.
However, she said while St John accepted its errors, it was unknown whether an earlier arrival would have prevented the tragic outcome.
St John had taken steps to learn from the mistakes, it told the coroner, including a review of delayed patient treatment to identify where errors were occurring, such as dispatch protocols.
In November last year St John met Jose to apologise and explain what action it was taking to prevent similar delays in future.
Dunn ruled Simon died from a heart attack and no further inquiry into her death was needed.
