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Emergency call centre staff have admitted a nearly 40 minute delay in sending an ambulance to a boy involved in a fatal bicycle crash.
Keegan Lawrence, 14, fell and landed head-first while jumping his bike at Paremata, north of Wellington, on October 25, 2007.
A schoolboy dialled 111 at 3.44pm after seeing the accident from a passing train, but the ambulance communications centre staff member who took the call only dispatched a police car to investigate, The Dominion Post reported.
An ambulance 15 minutes away had been available, but was not dispatched.
When an ambulance finally arrived to Keegan's aid at 4.22pm, staff revived him, but he died in Wellington Hospital the next day.
St John Ambulance communications centre manager Jacqui Eades told an inquest yesterday that her own investigation had found the person who took the initial call should have asked an ambulance to respond with the highest priority.
Instead, they placed the ambulance request on hold believing no ambulances were available before requesting police assistance.
Both actions went against standard procedure and at least one ambulance could have responded within 15 minutes, Mrs Eades said.
Keegan's father, Mason Lawrence, said he and his wife Chrissy were told of the mistake and were apologised to at a meeting with communications centre staff two months ago.
"Up to that point we'd accepted at face value ... that there wasn't (an ambulance) at their disposal. We were gutted. I had to leave."
Although a neurosurgeon's report for the inquest had found that the head injury Keegan suffered was usually fatal, the couple would always wonder what might have been if an ambulance had arrived earlier, Mr Lawrence said.
Mrs Eades said the staff member who took the 111 call was still employed at the centre but had received extra one-on-one training since the incident.
"They're quite devastated by the experience. They've certainly learnt from what they've done ... and we're happy that they're performing safely."
Wellington coroner Ian Smith has reserved his findings.