The son of a Gisborne farmer who died after falling two
metres has told an inquest the standard of care his father
received from St John Ambulance was unacceptable.
Simon Kirkpatrick hopes no other family will have to endure a
John Alexander Kirkpatrick, 72, died on January 14, 2013,
after falling from hay bales on a tractor. At an inquest in
Gisborne yesterday, the coroner was told the call to St John
came at the same time as two ambulances and available staff
were dealing with a critical cardiac case.
Simon Kirkpatrick questioned the quality of care provided to
his father and criticised an ambulance officer for getting
The family could have driven his father to hospital within 10
minutes, he said.
"We were let down."
Coroner Ian Smith said everyone made mistakes in their
vocation, including himself in past careers as a civil
engineer and lawyer.
"Sometimes we have to make a call."
It was unfortunate that a mistake made in the medical
profession could have fatal consequences.
A decision to transport a family member to hospital was a
decision for a family to make.
But there were times when such a decision could also have
fatal consequences, said Mr Smith.
The court heard Mr Kirkpatrick landed on his head.
He was pronounced dead at Gisborne Hospital at 10.29am.
The first 111 call was made at 8.09am at a time when two
Gisborne ambulances were attending a cardiac arrest incident
- a standard procedure.
The first ambulance arrived at the Kirkpatricks' Wharekopae
Road property at 8.41am.
Simon Kirkpatrick said the lone ambulance officer took the
wrong route and appeared stressed and unsure of what to do.
He felt sorry for the officer who had been put in such a
position by St John.
Dr Craig Ellis, deputy medical director of St John, said an
intensive care paramedic, a paramedic and two basic life
support medics from the two Gisborne ambulances were required
and busy at the cardiac arrest.
Mr Kirkpatrick's incident had originally been graded by an
Auckland dispatcher and not deemed to be life threatening.
One of the basic life support medics was sent from the
cardiac arrest to Wharekopae Road when that ambulance officer
A second 111 call was later received, indicating Mr
Kirkpatrick's condition had deteriorated and the priority
rating was upgraded.
Dr Ellis said the system was not perfect.
St John received thousand of calls each day and operated with
Ambulances were equipped with GPS and he could not explain
how the first ambulance officer ended up on the wrong road.
Stephen Smith, St John district operations officer, said the
officer was in a challenging situation and followed the first
aid "ABC rule" in tending Mr Kirkpatrick's "compromised"
Intubation was tried by an officer who arrived later.
Dr Ellis said the other officers were treating someone who
was critically ill and faced a difficult ethical situation of
going to see another patient who might not need them.
It would have been ideal to send two ambulance officers but
that was not possible at the time.
Tairawhiti District Health now funded a third ambulance,
which was used for transport but was also available to
respond to emergencies.
The chances of what happened in Mr Kirkpatrick's case
occurring again had been lowered but not eliminated.
Dr Ellis and Mr Smith said a rapid response unit manager had
been established in Gisborne since Mr Kirkpatrick's death.
Gisborne ambulances now had additional staff and there was a
national memorandum of understanding with the fire service to
help ambulance officers.
The funding issue "was being looked at".
Simon Kirkpatrick questioned how the first ambulance officer
could remember and record events that did not correspond with
his memory of events, in a report prepared months later for
St John had no system for recording deaths and he could not
see any lessons being learned.
The coroner said he was astounded that ambulance officers did
not create more extensive documentation than their
contemporaneous patient record forms. He expected further
records if someone died.
Pathologist Dr Katharine White said the cause of Mr
Kirkpatrick's death was a combination of difficulty in
getting oxygen into the lungs and loss of blood from severe
tongue injuries suffered in a fall.
Mr Kirkpatrick was an aged man and existing coronary disease
contributed to his death.
Mr Kirkpatrick was resuscitated from one cardiac arrest and
He also suffered spinal injuries but Dr White did not think
that contributed to his death.
The coroner reserved his decision.
- Gisborne Herald