An elderly man died just minutes after paramedics assessed him as not needing to be transferred to hospital, a report reveals.
Findings released on Monday by the Deputy Health and Disability Commissioner, Rose Wall, show two paramedics failed to properly assess a 73-year-old man's shortness of breath in 2016.
It states the paramedics, only referred to as "Mr B" and "Mr C", were called to the man's home to find him sitting on the edge of his bed around 11pm one evening.
They examined him, recorded his vital signs and then made the decision not to bother taking him to hospital. Instead they advised the man to visit his GP the following morning.
Twenty-eight minutes later, the 73-year-old collapsed. Once again, an ambulance was called, involving the same paramedics who attended earlier along with another. Efforts to resuscitate him were unsuccessful.
Ms Wall found the paramedics failed to check his blood glucose, temperature, capillary refill or pain score, among other things considered standard practice.
She adds while Mr B obtained the man's medical history, finding his medication for diabetes, Mr C missed it altogether.
It's made clear in the report that the breaches in conduct fell on the part of the paramedics and not on the ambulance service.
In a statement to the Herald, St John's medical director Tony Smith says they accept the findings and have since apologised to the family for failing to provide them with the best possible care on this occasion.
"The two paramedics remain employed with St John," he says.
"We wish to assure the public that we take patient safety and wellbeing extremely seriously and have taken learnings from this case to improve the service we deliver."
Ms Wall has recommended that the paramedics involved write an apology to the man's family, provide a progress report of their work since the complaint, undertake further training specific to recognising abnormal vital signs and undertake two refresher courses.