An intellectually disabled man who waited almost three hours outside for an ambulance in excruciating pain, had a spinal infection that could have killed him if left untreated.
David Stevens was triaged by St John as non-urgent when he collapsed in a friend's driveway with back spasms one night late last month. He was in so much pain he couldn't be moved inside so a friend covered him with blankets and waited by his side.
When he was finally taken to Dunedin Hospital the 54-year-old was X-rayed and discharged home alone in a taxi the next day.
It was only when his older sister and guardian Jane Stevens complained to Minister of Health Chris Hipkins a few days later, that her brother was recalled to hospital.
A series of tests including a biopsy and MRI scan revealed the slow-growing infection in David's spine which Jane says doctors told her could have developed into sepsis - a life-threatening complication of infection.
David spent nine days in hospital and has been discharged home on intravenous antibiotics for the next six weeks to fight the infection.
Jane, who lives near Hamilton, said her brother had been repeatedly urgently referred by his GP to a rehabilitation service at Wakari Hospital for assessment of the debilitating spasms which had plagued him for about 18 months.
But David had not been seen by the time he collapsed outside an Idea Services house at 5pm on August 30, where he had been visiting friends.
"Based on this latest experience I am left despairing of how I am going to be able to keep my ailing brother safe and with a decent quality of life," Jane wrote to Hipkins on September 3.
"We were already struggling to get him access to a full medical assessment, in spite of his doctor repeatedly referring him for an urgent assessment he has been turned away.
"Both his GP and I have come to the conclusion that the biggest barrier to him getting treatment is a discrimination against people with complex health and disability challenges."
She called for better treatment of society's vulnerable.
"Isn't the measure of a caring society meant to be based on how we look after our most vulnerable? That's not what is happening here."
She pointed out David's need for emergency services that night and on several earlier occasions was largely the result of not being able to get any progress on diagnosis and appropriate treatment for his back spasms.
"It is also not acceptable for intellectually and physically disabled people to receive a lower level of care than able minded and bodied people."
She said medical professionals had made assumptions that David's back spasms were due to his deteriorating physical frame, which is now severely stooped, requiring a walker and sometimes a wheelchair to get around.
It was the same with David's twin Peter, Jane said, who died at age 46 in 2012 when oesophageal cancer symptoms were missed and it spread to his brain.
The identical twins lived together with support from disability services and his brother's death had a profound impact on David. Jane said Peter's death might have been preventable.
"He was also disabled and there was a significant delay in getting medical treatment and diagnosis leading to his premature death. As you can imagine this has affected David significantly."
The twins were born with intellectual disabilities after being deprived of oxygen at birth when their mother had a heart attack during delivery.
It was 1965 and Phyllis Stevens was two weeks overdue with triplets. The third infant died at birth and Phyllis suffered life-long health problems after the heart attack.
But the twins never let their disabilities hold them back and both competed at the Special Olympics; Peter in walking after he could no longer run marathons, and David as a swimmer.
They also both worked and Peter was an advocate for the disability sector.
Idea Services area manager Zelda Jordan said it was not the first time clients had faced a long wait for an ambulance.
"We need better resourcing for ambulances so they can more quickly get to the people who so badly need their help."
St John Coast Otago territory manager Doug Third said while the objective was to respond as soon as possible, life-threatening calls were given the highest priority and at the time of the incident all Dunedin ambulances were responding to other jobs.
"A clinical support officer made two welfare checks on the patient, and at 7pm, we were advised that the patient's condition had changed, and an ambulance was dispatched, taking him to Dunedin Hospital in a moderate condition."
Jane said there was never anyone on site in a position to make a medical assessment and St John staff never spoke to David or made contact with her as his welfare guardian.
She asked Hipkins for assurances her concerns over funding of the ambulance service and difficulties she was having accessing medical care for David would be addressed.
In a response the same day a member of Hipkins' office wrote: "I am very sorry to hear of your brother's situation, and I understand this must be very distressing for you and your family".
"The Minister has asked his officials to advise him on this matter and will respond in due course."
A spokesman for Hipkins said he would be responding to Jane soon.