A coroner has recommended ways to improve the way St John and Police communications deal with emergency calls in the wake of delays and errors made when a man died during last year's Motatapu Icebreaker mountain bike event.
Coroner David Crerar said he wanted to make recommendations for improving the system to prevent a similar tragedy.
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.
The inquest, in February, heard the person who took the emergency call made several errors and caused delays, but they did not contribute to Const Schriek's death.
In his findings released yesterday, Mr Crerar recommended that St John Communications should take steps to ensure call details were entered into the database as soon as possible and to better prioritise allocating rescue resources.
He said the police should create a formal process to more accurately record advice from event organisers so it can be accessed by rescue and emergency services.
The police southern communications centre should "enhance its processes and procedures as a result of lessons learned from the tragic death of Jacob Schriek; specifically the more accurate recording, cross-referencing and tracking programmes ... and a more accurate method of incident identification", he said.
Mr Crerar also recommended the adventure race promotion and organisation industry should co-operate to establish an industry standard for risk management during events.
He found Const Schriek died of a "severe cardiac event and was unable to be resuscitated".
An autopsy found he was suffering from coronary artery disease.
Motatapu's head medic Michel Lepage came across Const Schriek during the race struggling to breathe and with acute chest pain.
Mr Schriek told him he had a coronary stent inserted five years previously. Mr Lepage administered oxygen and radioed race director Tracey Neil, asking her 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.
Ms Neil yesterday said she had met other New Zealand adventure race organisers to discuss ways of improving risk management and to create an industry standard, as recommended by Mr Crerar.
She said changes had been made to this year's accident and emergency procedures.
The number of medics on the team had been increased from three to seven, including highly trained mountain guides who could administer adrenaline or IV drugs.
She said pre-race briefing with Wakatipu St John and local police had been improved.
SCHRIEK CASE
Time line
- 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 Wanaka.