If you're about to have a heart attack, the safest place to be would surely be the hospital. And the safest place in the hospital, you might think, would be the accident and emergency department. But for one Wellington woman the very place that should have saved her life neglected to do so.
Her family has spoken of their love for Poia Strickland-Laumemea, but not deep beneath the surface is hurt – real hurt.
One Sunday Anitelea Laumemea went with Poia by ambulance to hospital. She never came home.
Matriarch of a proud, devout family, Poia had three children. Paula is her eldest.
Poia was also a mother to an entire community – a Porirua social worker loved by many, gone too young, dead at just 51.
For the first time Poia's extended Rarotongan-Samoan family has met to talk about how she died and their anger at what went wrong and why.
A report just released by the Health and Disability Commissioner is damning of her treatment and sets out how it failed.
Poia arrived by ambulance in emergency, suffering chest pain and shortness of breath. She was seen by a nurse, but it took an hour and a quarter before she was assessed by an emergency doctor.
Blood tests and an ECG were ordered and an X-ray taken, but somehow the X-ray results weren't looked at.
The blood tests showed raised potassium levels – a danger sign for a heart attack – but it was seven hours before they were properly reviewed.
Nearly 12 hours after she arrived, Poia finally received treatment for the by-now dangerously high potassium levels, but it was too late. Within half an hour, her heart had stopped.
It's hard, and not just for the kids, to understand Poia's death because it was unnecessary.
The Capital and Coast District Health Board does accept that it failed Poia. The care provided to her was a serious departure from accepted standards.
She should have been seen by a doctor within 10 minutes but wasn't because it was a busy Sunday afternoon.
She wasn't monitored properly as she deteriorated through the evening. It's clear from changes since that under-staffing was an issue.
She was never once seen by a senior doctor.
When it was finally realised how serious Poia's symptoms were, the treatment was too slow.
Daughter Paula coincidentally was already in the same hospital, in the maternity ward, having given birth two days earlier. So Poia was accompanied by her husband and son-in-law.
Joseph Laumemea is now 14 years old, the youngest of Poia and Anitilea's children. He was only 11 the day his mum went into hospital.
With the ED so busy, it was Joseph who wheeled Poia in her trolley bed for her X-ray and it was he who after his mother's death asked what had happened to the results.
"There is the question I asked the nurse," he says. "I asked the nurse what her X-ray results were. All she told me was that her heart was getting bigger. At the time I didn't know what that meant. I didn't know if it was either good or bad."
What it is is a symptom of an underlying condition that should be checked. But remember the X-ray wasn't even looked at in time.
"They weren't aware of her enough. It's like they didn't care about her."
The family wanted and understood there would be a post-mortem examination. There wasn't. Now the family wants answers.
We tried to ask those questions on behalf of the family and were referred to a media spokesman, but they wouldn't budge.
Poia's care simply wasn't good enough. In remembering her and celebrating a life cut too short, her family hopes others, especially Pacific Island families, will speak up and demand better care, demand that their loved ones not be neglected.