Barbara McGee, a 67-year-old woman from Auckland, died in her home four hours after calling emergency services for help. The incident has raised serious concerns over ambulance response times and procedures in New Zealand.

McGee, who suffered from emphysema, called 111 at around 3 a.m. on Christmas Eve 2022, reporting difficulty breathing. Initial assessments incorrectly categorized her call as an 'orange' priority — serious but not immediately life-threatening. This led to a delay in sending an ambulance, which arrived four hours later. By then, McGee had passed away in her sleep.

Coroner Erin Woolley's investigation revealed that the call-taker had failed to accurately assess McGee's condition. Despite her obvious breathing difficulties, the handler recorded her response to a question about speaking between breaths as 'no,' when in fact, McGee was clearly struggling to breathe. This miscommunication likely downgraded the urgency of her call, resulting in a slower response.

Welfare checks, which are supposed to be conducted every 30 minutes, were also not followed correctly. McGee could not be reached during a second check at 5:30 a.m., and no further action was taken to reassess the situation. Coroner Woolley emphasized that if these procedures had been properly followed, the outcome might have been different.

McGee's family had visited her the day before, when she was already experiencing flu-like symptoms, including fever, weakness, and sleepiness. Her son received a final message from her before she fell asleep, expressing her intention to go to the hospital. He only learned of her death when police informed him upon his arrival at her house the next morning.

Following the incident, Hato Hone St John, the ambulance service involved, acknowledged the shortcomings in their response. Damian Tomic, Deputy Chief Executive of Clinical Services, stated that the organization had apologized unreservedly and extended condolences to McGee's family. The service also committed to making significant improvements in how welfare checks are conducted, including more timely follow-ups and clearer, more safety-focused procedures for call-backs.

This tragedy is not an isolated case. In recent years, there have been multiple reports of delays in ambulance response times, leading to preventable deaths. The Health and Disability Commissioner has received over 160 complaints related to Hato Hone St John since 2019, with two of those involving fatalities due to delayed ambulance arrivals.

Coroner Woolley's findings highlight the urgent need for improved training and clearer procedures for emergency call handlers. The coroner recommended that all call-takers be reminded of the importance of welfare checks and that if contact cannot be made with a patient, attempts should be made every five minutes, with a reassessment if there is no response.

As New Zealand grapples with a growing demand for emergency services, the McGee case serves as a sobering reminder of the importance of timely and accurate assessments in emergency situations. The recommendations from the coroner may help prevent similar tragedies in the future, but they also underscore the critical need for systemic improvements in emergency care.