78-year-old Margaret Wells passed away after waiting over an hour for an ambulance to arrive while experiencing a heart attack. Coroner Mary-Anne Borrowdale criticised the decision by Hato Hone St John to send its available ambulance to a less urgent incident instead of directly to Wells, who was unresponsive by the time help arrived.
In the early hours of 20 September 2020, Wells woke her husband Alfred, asking him to call an ambulance as she was experiencing chest pains, vomiting, and sweating. Alfred called 111, reporting his wife's condition as a heart attack. Despite his urgency, no ambulance arrived by 3:40 am when Alfred called 111 again, stating his wife was not breathing, Stuff reported.
The call handler instructed Alfred to place his wife on the floor for resuscitation. Despite being a double amputee and initially unable to lift her, he managed to do so. The call handler then guided him on how to administer CPR. It was not until 3:46 am that the ambulance crew arrived, finding Alfred attempting CPR on his unconscious wife. Despite their efforts, Margot was pronounced dead at 4:20 am from a heart attack.
An autopsy confirmed the cause of death, but the coroner's inquiry focused on St John's response to the emergency. The first call was categorised as "red", the second-highest priority, but no ambulance was available due to prior commitments. Despite being reassigned later, the delay contributed to the tragic outcome.
Coroner Borrowdale recommended that St John expand its questioning during emergency calls to gather information about any impediments preventing the caller from assisting the patient until help arrives. She also suggested increasing priority when the patient cannot receive essential assistance from the caller or others present.
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