But it says the delays in getting her to Palmerston North Hospital did not contribute to her death as it released the results of an internal investigation yesterday, The Dominion Post reported.
Three-year-old Cherishsiliala Tahuri-Wright, known as Cherish, suffered severe head injuries at a house in Marton on February 17, police allege. A 56-year-old woman has been charged with her murder.
Delays in getting specialised help to insert a breathing tube meant it took nearly two and a half hours to get Cherish to hospital, despite it being just a 40 minute drive away.
She was then flown to Wellington Hospital's neurological unit but her life support was switched off the next day.
St John Ambulance medical director Tony Smith said the initial emergency response was immediate but the "broader clinical picture and the need for rapid transport were lost".
Spending nearly two hours trying to stabilise Cherish at the scene was "excessive" and it would have been quicker to take her to hospital by road and have her breathing tube inserted there.
However, the emergency medicine specialists' review found the transport delay did not contribute to her death.
The personnel involved became focused on their own particular role and tasks, with nobody taking an overall view, Dr Smith said.
St John Ambulance would improve its responses in future with similar cases, he said.
Porirua Deputy Mayor Litea Ah Hoi, who spoke on behalf of Cherish's father, Nofosione Wright, said she was "really pleased" St John Ambulance had fronted up to its mistakes and was making changes.
