Jacob Schriek (55), a Riversdale police officer, died after suffering chest pains on the Golspie Burn track during the 50km race from Glendhu Bay near Wanaka to Arrowtown, through the high country station of singer Shania Twain, on March 14 last year.
Inspector Warren Peter Kemp investigated how the 111 call was treated.
He said the police communications call taker took too long to verify the location even after being given co-ordinates and other land locations, held on to the event for seven minutes before entering it into the system, failed to ask the condition of the patient and was unsure of what information to ask.
"She has had her blinkers on and gone down a path of destruction," he said.
Emergency ambulance communications centre operations manager Alan Goudge said police did not convey a sense of urgency regarding the incident or the patient's status.
"A delay of 23 minutes occurred between receiving the initial call from the police and the call taker entering the job details into [the ambulance system].
"While a delay of that length is not acceptable, during the 23-minute period SouthComm was making progress by requesting further information and attempting to arrange a helicopter crew to attend the scene," he said.
Both the Queenstown and Dunedin rescue helicopters were dealing with other incidents at the same time in Queenstown and Wanaka.
He said changes had been made to the recording of job details and training programmes.
Constable Chris Blackford said the police had "fronted up and explained the delays".
"The police and ambulance service have learned from this tragedy," he said.
However, he questioned why the race organisers did not have a helicopter on standby during the event and why the on-course doctor was also a competitor.
He questioned why the team of medics did not include a qualified paramedic and why they had only one bottle of oxygen.
Motatapu's head medic Michel Lepage said he was not a qualified paramedic but a pre-hospital first aid attendant with experience in wilderness first aid.
He said there were three other first aid personnel on the team, as well as the on-course doctor.
During the race, he came across Mr Schriek who was struggling to breathe and had acute chest pain.
Mr Schriek told him he had had a coronary stent inserted five years previously but he did not have angina.
Mr Lepage administered oxygen and radioed race director Tracey Neil to call 111.
He said Mr Schriek slipped out of consciousness when the oxygen ran out after about 25 minutes.
He, along with competitors including Dr Trudy Ballantine, course doctor Andrew Wilson, a dentist, and an ex-police officer with first aid training, began CPR using a defibrillator.
After about an hour, Mr Schriek was confirmed dead.
Dr Ballantine told the court she doubted whether a helicopter and paramedics would have made any difference to Mr Schriek's survival.
"Jacob needed not only CPR and defibrillation but oxygen accompanied with IV adrenaline and possibly fluid to improve his chance of survival," she said.
Ms Neil said changes had been made to this year's accident and emergency procedures.
More medics would be added to the team, including highly trained mountain guides who could administer adrenaline or IV.
Medics would also have more than one bottle of oxygen with them.
Pre-race briefing with Wakatipu St John and local police would be improved with a paramedic on standby.
"It was frustrating when communicating with police comms that they didn't understand the geography, particularly when we had given local police the details," she said.
Coroner David Crerar said he wanted to make recommendations for improving the system to prevent a similar tragedy from happening in future.
He reserved his findings and recommendations.
Schriek case
Timeline
- 1.05pm: Jacob Schriek first experiences chest pain
- 2pm: CPR commenced
- 2.09pm: 111 called
- 2.16pm: Event entered into system
- 2.19pm: Ambulance notified
- 2.27pm: Communications called race director back for location co-ordinates
- 2.42pm: Incident entered into ambulance system
- 2.45pm: Police and ambulance advised Mr Schriek had died.
- 2.51pm: Helicopter stood down.
Details
- Medic had only one bottle of oxygen
- No qualified paramedics on race medical team
- Police did not convey a sense of urgency to ambulance communications
- Police communications call taker had difficulty verifying location and delayed entering the incident into the system
- Queenstown and Dunedin helicopters were attending other events in Queenstown and WanakaJacob Schriek
