Otago-Southland coroner David Crerar held an inquiry into the death of Simon Berry and his finding was made public yesterday.
He said the cause of Mr Berry's death was an acute or chronic respiratory event that was consistent with asthma and delays in the arrival of St John ambulance staff and health professionals could have made a difference in Mr Berry's survival.
The inquiry was held in chambers and Mr Crerar heard evidence from police, Mr Berry's father Victor, St John staff and doctors.
Simon Berry was staying at the Cromwell home of his father and stepmother and called for an ambulance at 12.49am on September 5, 2009, saying he was having breathing difficulties, Mr Crerar said.
There were "technical issues" which caused delays in St John responding to the call. The ambulance arrived at the house at 1.15am and contacted the on-call doctor.
The St John pager network was "down", which added about eight minutes to the standard response time, and the duty doctor had forgotten to update the Cromwell Medical Centre telephone answering machine with an after-hours contact. This further delayed the attendance of a doctor at the scene, Mr Crerar said.
Mr Berry was an asthmatic.
"As a result of his breathing difficulties, Simon Berry called for an ambulance and while assistance was coming, he collapsed and went into cardiac arrest. Appropriate but not timely assistance was given," Mr Crerar said.
"The exact contribution of the delay in the arrival and implementation of resuscitation is impossible to assess. What is clear is that there were delays and that those delays were serious and they may have been contributory to the death of Simon Berry," he said.
One of the ambulance officers on call lived in a rural area where reception for cellphones and pager calls sometimes failed.
St John had since reviewed its systems and doctors in both Cromwell medical centres and St John ambulance officers had been given access to communications back-up facilities. Ambulance staff in the communications centre and in Cromwell had also been given after-hours contact numbers for the town's doctors.
Victor Berry said he thought the coroner's finding was "spot-on" but believed the same sequence of delays could happen again.
"I'm not at all confident it won't happen again ... and I'm sorry for whoever has to go through what we've been through. I wouldn't wish this on anyone."
He and his wife Gillian, Simon's stepmother, had "pushed for the truth to come out".
They were away in Ashburton when Simon suffered his asthma attack and received a call from police, almost two hours later, to say he had died.
"It was the first asthma attack he'd ever had," Mr Berry said.
St John Central Otago operations manager Peter Grayland said it was "a tragic event".
"As soon as we realised there were issues with the pagers, we straight away widened the scope of the system and backed it up and implemented a more robust maintenance schedule." Having said that, St John staff were "at the whim" of technology, he said.
"You can put everything into place, with the best equipment, and it can still fail."
Approached by the Otago Daily Times for comment on the coroner's finding, one of the partners at the Cromwell Medical Centre, Dr Brendon Pauley, said the centre had put "systems in place" to address the concerns raised in the inquiry about the after-hours calls.
"It was a very tragic event," Dr Pauley said.
Mr Crerar praised the input of Victor and Gillian Berry, saying without their "perseverance" significant and appropriate items of evidence might not have been disclosed. He also acknowledged the "candour" of St John staff and doctors involved.
