The deputy Health and Disability Commissioner has found that a St John 111 call-taker breached protocol when responding to reports of a man suffering a heart attack, who later died en route to the hospital.

In a decision released on Monday, Commissioner Deborah James concluded that the man's rights had been breached under the Code of Health and Disability Services Consumers' Rights.

The investigation centred on St John's management of two 111 calls from a woman about her husband who was suffering "heart attack symptoms".

The report said the woman made an initial call to 111, informing that her husband was breathing but in pain and "very red in the face".

The call was prioritised as "serious but not immediately life threatening".

About 30 minutes later, a dispatcher launched an "Initial Assign" tool to establish what ambulance availability there was.

It indicated a 27-minute wait and proposed a first response team from Fire and Emergency (FENZ).

The report said the St John dispatcher did not consider a FENZ first response team to be necessary, because the man was "completely alert, had no difficulty breathing, and had no cardiac history".

Around the same time, the woman had called 111 again as her husband's condition had worsened.

She raised concerns that an ambulance had not yet arrived and asked whether one was on its way, to which the St John call-handler said one was yet to be assigned because of high demand.

The woman told St John that she would transport her husband to hospital herself.

St John told the woman "if anything changed, she could phone back".

The man suffered a cardiac arrest three minutes from the hospital and could not be revived by Emergency Department (ED) staff.

James said the second call handler had deviated from St John's standard operating procedures.

"The St John incident review identified that when [the woman] advised [the St John call-taker] that she would take [the man] to hospital herself, there was a need for [St John] to advise [the woman] that it might be a good idea to continue waiting for the ambulance response.

"I note that [the St John call-taker] failure to re-triage [the woman's] second 111 call may have affected her decision not to advise [her] to wait for the ambulance to arrive."

Despite the man's wife telling the call handler that her husband's condition had worsened, the call handler did not ask for any further information about his symptoms, the report said.

"The code stipulates that all consumers have the right to have services provided that comply with professional and other relevant standards.

"St John's standard operating procedures stated that welfare checks were to be completed every 30 minutes if an ambulance was unable to be dispatched."

The commissioner found St John had also failed the man by not meeting expected wait times when there was a 30-minute delay in using the Initial Assign tool, nor was a welfare check undertaken.

"There will undoubtedly be times where ambulances are unavailable to respond to incidents immediately," James said.

"However, it is St John's responsibility to find ways to mitigate the risks associated with unavailable ambulances.

"In my view, conducting welfare checks every 30 minutes (as outlined in St John's SOP) is an appropriate tool in mitigating such risk."

She also found St John breached the code by not providing the man, via his wife, with information he could have expected to receive under the circumstances.

This included not conducting a welfare check and not advising the woman about delays in dispatching an ambulance, or advising her to wait for an ambulance response.

"I am critical that this information was not shared, particularly as [the woman] has indicated in her complaint that had she known the ambulance would be delayed, she would have transported [her husband] to hospital earlier."

James recommended the St John call handler formally apologise to the woman.

She also recommended St John provide additional training for call handling and dispatch staff on the importance of welfare checks, and to update its dispatching guides to be clearer about how to use the Initial Assign tool.

In response to the report, St John has "unreservedly" apologised for its failures that day.

In a statement, St John head of clinical governance Jon Moores said it accepted the report's findings.

"We apologise unreservedly to the patient's wife and their family for failing to deliver the appropriate standard of care and for the distress this may have caused.

"St John is always looking at ways to improve our systems and guidelines to ensure we provide patients with the best level of care we can."

The organisation was working its way through the Deputy Commissioner's final recommendations, and committed to learning from the report's findings, Moores said.

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