Auckland Man Dies After Ambulance Delay, Coroner Expresses Concern Over 'Serious, Compounding Mistakes'

A tragic incident in Auckland has raised serious concerns about emergency response procedures, as a 72-year-old man, Wenyi Chen, died after a significant delay in ambulance dispatch. Coroner Janet Anderson has expressed deep concern over the "serious, and compounding, mistakes" made in handling the emergency calls, which ultimately led to a fatal outcome.

The Incident

On a rainy evening in October 2022, Wenyi Chen and his wife were returning home from a friend's house when he tripped and fell off the side of a driveway, sustaining a severe spinal injury. Despite immediate efforts by family and friends to provide first aid and perform CPR, an ambulance did not arrive for 45 minutes. During this time, two ambulances were dispatched but were redirected to higher-priority calls, and it took five separate 111 emergency calls before help finally arrived.

Coroner's Findings

Coroner Janet Anderson, in her findings, highlighted the critical errors in the emergency response system. She noted that the initial call to emergency services was categorized as "orange," indicating a serious but not immediately life-threatening situation. However, this triage decision led to a delayed response, and it was only after a fifth call that the situation was reclassified as a "cardiac/respiratory arrest," prompting a higher-priority response.

Anderson expressed her "deep concern" over the number of mistakes made in the handling of the emergency calls, which ultimately resulted in a fatal delay. She emphasized that accurate triaging and assessment of emergency calls are essential components of a safe ambulance service, and in this case, the system failed to meet those standards.

Broader Concerns

This incident is not an isolated case. The coroner also referenced two other cases where delays in ambulance response led to fatalities. In one case, a teenager named Tayla Brown died in July 2020 after a 28-minute wait for an ambulance following an asthma attack. In another case, a man experiencing "classic heart attack symptoms" died as his wife drove him to the hospital after an ambulance had not been dispatched for nearly an hour.

These incidents have prompted calls for a thorough review of emergency call handling procedures and training for call takers. Anderson recommended that the emergency service review its policies and processes, and consider whether additional training and support is required for any of the call takers involved in the incident.

St John's Response

St John, the emergency service provider, has acknowledged the errors made in its operating procedures and triaging that night. Damian Tomic, the service's deputy chief executive of clinical services, stated that the organization apologizes unreservedly for what had happened and the distress caused to Chen's family. He added that St John has offered to meet with the family to share its apology in person, and that offer remains open should they wish to do so.

Tomic also emphasized that the focus is on ensuring the highest possible standard of care and communication at every point of contact. He noted that 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.

Conclusion

The tragic death of Wenyi Chen has highlighted the urgent need for improvements in emergency response systems. Coroner Anderson's findings underscore the importance of accurate triaging and the potential consequences of system failures. As St John works through the recommendations, the focus remains on ensuring that such incidents do not occur in the future, and that the highest standards of care are maintained at all times.