The 72-year-old died before paramedics got to the Auckland address, as his family watched him deteriorate.

St John has conceded there were errors made in its operating procedures and triaging that night.

A coroner’s finding has also revealed “deep concerns” over the number of “serious, and compounding, mistakes made” in dealing with the 111 calls, which resulted in a significant delay in dispatching an ambulance to the scene.

It comes after NZME reported in January this year that the Health and Disability Commissioner had received 166 complaints involving Hato Hone St John from July 1, 2019, to June 30, 2024.

They included two cases where people died because of delays in the arrival of ambulance crews.

One was teenager Tayla Brown who died in July 2020, after a 28-minute wait for an ambulance following an asthma attack.

The other was a man experiencing “classic heart attack symptoms” who died as his wife drove him to hospital after Hato Hone St John had still not dispatched an ambulance almost an hour after she made the first 111 call for help.

In the more recent case, St John acknowledged that the errors in dealing with the 111 calls resulted in a delayed response of about 45 minutes.

The service’s deputy chief executive of clinical services, Damian Tomic, told NZME the organisation apologised unreservedly for what had happened and the distress caused to Chen’s family.

“We have offered to meet with the family to share our apology in person, and that offer remains open should they wish to do so.”

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Fatal fall

Coroner Janet Anderson said in her decision that Chen and his wife had been visiting friends. It was raining heavily when they left the house at around 7.30pm on October 1, 2022.

Chen was walking quickly down the driveway towards their car when he appeared to trip and then fall into a garden area about 1m below the driveway.

He was initially conscious but indicated that he was “not okay”.

Emergency services were called, but Chen’s condition deteriorated and he became unresponsive.

Friends and family members removed him from where he lay and started CPR.

St John received the first emergency call at 7.39pm to say Chen had fallen and was unconscious.

The call was coded “orange”, indicating that the event appeared serious but was not immediately life-threatening, Anderson said.

An ambulance was sent at 7.44pm, but two minutes later the vehicle was reassigned to a higher-priority event. A second ambulance was dispatched, but that, too, was reassigned.

A third 111 call was received by St John at 8.06pm followed minutes later by a fourth.

At 8.15pm a fifth emergency call was made, by which time Chen was unconscious and not breathing.

Anderson said this call was then re-triaged by St John as “cardiac/respiratory arrest” and given a purple priority.

An ambulance was dispatched at 8.17pm and a call was made to Fire and Emergency NZ requesting assistance.

Efforts were made to resuscitate Chen, but he was not able to be revived.

The coroner was unable to conclude if Chen might have lived had the ambulance arrived sooner, saying there was a slim chance, but possibly with “permanent, significant” neurological injury to his limbs and his breathing.

She said accurate triaging and assessment of emergency calls was an essential component of a safe ambulance service.

“This did not happen in Wenyi’s case. Wenyi and his family were let down by the Hato Hone/St John emergency service,” Anderson said in her written findings.

St John accepts coroner’s findings

Anderson recommended that the service review its emergency call taker policies and processes, and associated training, and consider whether additional training and support was required for any of the call takers involved in the incident.

Tomic said St John accepted the coroner’s findings and was working through the recommendations.

He said the focus was on ensuring the highest possible standard of care and communication at every point of contact.

In the five years from 2019 St John received 3.1 million calls and responded to 2.1 million.

While the number of annual complaints about the service fluctuated over that time, they almost doubled from 26 in 2019-20 to 49 in 2023-24.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.