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"I'm lying on my back, one of my hands are numb and one of my legs I can't move ... my spine is very sore when I move."
Those were the chilling words a woman in her 30s screamed through the phone after dialling 111 for an ambulance.
Her partner had found her lying on the floor at 1am after consuming alcohol. The woman told St John staff that she couldn't remember how she fell and that she had been drinking alcohol.
Ten minutes after calling for an ambulance, two Emergency Medical Technicians (EMT) arrived on the scene and decided she had slipped off the couch due to intoxication.
They "prematurely" cleared the woman of a possible spinal injury and decided she didn't need to be taken to the hospital.
Less than seven hours later, the woman called another ambulance as she was still unable to move her left side.
This time crew flagged a "potential threat to life" and she was immediately rushed to hospital where she was diagnosed with a spinal cord injury.
Three years on from that traumatic day, she still can't walk properly and relies on a wheelchair or crutch to get anywhere.
Today, a major investigation by Government-funded health watchdog agency the Health and Disability Commission (HDC) has forced St John to apologise to the woman for the "biased" judgment.
In a decision report released today, deputy Health and Disability Commissioner Rose Wall said the two EMTs were "inadequately equipped" and biases likely affected their clinical judgment.
"St John has a duty to ensure that its staff, particularly more junior staff, are supported adequately at all times to manage challenging clinical scenarios when they arise," she said.
Wall found St John in breach of the Code of Health and Disability Services Consumers' Rights (the Code) for failing to provide an appropriate assessment of a woman with a spinal injury.
The deputy commissioner recommended St John report any further instances of inadequate documentation and the actions taken to address any issues.
She also advised them to provide training to staff on when to call the clinical desk for guidance and to review its "non-transport criteria" and the associated staff training.
St John and both EMTs were ordered to provide written apologies to the woman.
The two EMT staff and St John all told HDC that they agree with the proposed recommendations.
In the report, the woman said she felt the ambulance crew were trying to say that she was totally intoxicated and not co-operating with them, which she said, was untrue.
She acknowledged that she had had a few drinks but said she was not unco-operative.
The woman also said she felt they were not listening to her or taking on board what she was saying about her state at the time. She was concerned that the EMTs left her in the state she was in, and that they moved her when she believed they should not have.
One of the EMTs told healthcare investigators the incident had been "a huge learning curve" and apologised "for getting this wrong".
"I may have experienced tunnel vision which caused me to not consider a traumatic brain injury."
The other staffer said: "At the time of this incident, I feel my experience was quite low dealing with patients like [Ms A] … however, I also accept that I am an EMT and I am really sorry if I have missed something that I should have recognised."
- Names were excluded from the HDC report, citing privacy reasons.