An ambulance service has been slammed by the Health and Disability Commissioner after a 69-year-old woman died in the back of its vehicle.
The ambulance was called out to a woman rural property in 2013, after her daughter hit her mother's emergency medical alarm when she began having problems breathing and chest pains.
The mother had a chronic obstructive airways disease and was using oxygen 24 hours a day.
After an initial assessment by a paramedic and a volunteer, she was not transferred to hospital but the daughter was asked to call again if her mother's condition worsened.
Around four hours later the daughter called 111 again, and the paramedic was dispatched to their house but he was unable to page or wake the volunteer to assist him.
Upon arriving he recognised the mother's condition had worsened significantly and required transportation to hospital.
However, without the volunteer to help in moving her, the mother was made to walk eight metres to a wheelchair outside the front door without oxygen as the paramedic did not bring any portable bottles with him.
While the daughter and paramedic were wheeling the sickly woman to the ambulance, the wheelchair tipped over with the mother still strapped in.
She then collapsed as she tried to make her way to the ambulance.
The paramedic drove the woman to hospital, but did not stop when alarms went off warning him that her oxygen levels were low.
She died on route.
Deputy Health and Disability Commissioner Theo Baker asserted that while much of the blame rested on the paramedic, the ambulance service also failed the woman by its communication errors.
The pager failure which left the paramedic without an assistant "happens quite often", the paramedic said, despite there not being any reported pager issues at the time of the incident.
The paramedic has had his responsibilities reduced following the death, and Ms Baker said that his assessment and treatment of the woman was seriously inadequate.
Ms Baker recommended the paramedic write an apology to the family of the mother and to review his practice in light of her report.
The ambulance service was recommended to provide additional staff training on various matters, to audit pager failures for six months and report back on that audit and any remedial steps taken.