"We were let down."
Coroner Ian Smith said everyone made mistakes in their vocation, including himself in past careers as a civil engineer and lawyer.
"Sometimes we have to make a call."
It was unfortunate that a mistake made in the medical profession could have fatal consequences.
A decision to transport a family member to hospital was a decision for a family to make.
But there were times when such a decision could also have fatal consequences, said Mr Smith.
The court heard Mr Kirkpatrick landed on his head.
He was pronounced dead at Gisborne Hospital at 10.29am.
The first 111 call was made at 8.09am at a time when two Gisborne ambulances were attending a cardiac arrest incident -- a standard procedure.
The first ambulance arrived at the Kirkpatricks' Wharekopae Road property at 8.41am.
Simon Kirkpatrick said the lone ambulance officer took the wrong route and appeared stressed and unsure of what to do.
He felt sorry for the officer who had been put in such a position by St John.
Dr Craig Ellis, deputy medical director of St John, said an intensive care paramedic, a paramedic and two basic life support medics from the two Gisborne ambulances were required and busy at the cardiac arrest.
Mr Kirkpatrick's incident had originally been graded by an Auckland dispatcher and not deemed to be life threatening.
One of the basic life support medics was sent from the cardiac arrest to Wharekopae Road when that ambulance officer became available.
A second 111 call was later received, indicating Mr Kirkpatrick's condition had deteriorated and the priority rating was upgraded.
Dr Ellis said the system was not perfect.
St John received thousand of calls each day and operated with limited resources.
Ambulances were equipped with GPS and he could not explain how the first ambulance officer ended up on the wrong road.
Stephen Smith, St John district operations officer, said the officer was in a challenging situation and followed the first aid "ABC rule" in tending Mr Kirkpatrick's "compromised" airways.
Intubation was tried by an officer who arrived later.
Dr Ellis said the other officers were treating someone who was critically ill and faced a difficult ethical situation of going to see another patient who might not need them.
It would have been ideal to send two ambulance officers but that was not possible at the time.
Tairawhiti District Health now funded a third ambulance, which was used for transport but was also available to respond to emergencies.
The chances of what happened in Mr Kirkpatrick's case occurring again had been lowered but not eliminated.
Dr Ellis and Mr Smith said a rapid response unit manager had been established in Gisborne since Mr Kirkpatrick's death.
Gisborne ambulances now had additional staff and there was a national memorandum of understanding with the fire service to help ambulance officers.
The funding issue "was being looked at".
Simon Kirkpatrick questioned how the first ambulance officer could remember and record events that did not correspond with his memory of events, in a report prepared months later for the inquest.
St John had no system for recording deaths and he could not see any lessons being learned.
The coroner said he was astounded that ambulance officers did not create more extensive documentation than their contemporaneous patient record forms. He expected further records if someone died.
Pathologist Dr Katharine White said the cause of Mr Kirkpatrick's death was a combination of difficulty in getting oxygen into the lungs and loss of blood from severe tongue injuries suffered in a fall.
Mr Kirkpatrick was an aged man and existing coronary disease contributed to his death.
Mr Kirkpatrick was resuscitated from one cardiac arrest and suffered another.
He also suffered spinal injuries but Dr White did not think that contributed to his death.
The coroner reserved his decision.
- The Gisborne Herald
