A desperate man was forced to drive his heavily bleeding father to hospital in the work van after he became frustrated that no ambulance was coming.
The 43-year-old had suffered a deep cut to an artery in his arm when he was loading glass and timber into a bin on a building site in 2021. He died later that day.
The ambulance arrived at the site more than 30 minutes after the man was already in hospital.
Health and Disability Commissioner Morag McDowell has criticised St John for multiple failings with its systems in relation to the incident in an unidentified town or city.
The man's son saw the accident happen and called the ambulance at 3.39pm because the cut was deep and bleeding significantly.
His father was slipping in and out of consciousness during the call.
The son told the call taker it was a dangerous injury, "he's completely bleeding" and, later "he's going to bleed to death," the report said.
She provided advice to try to stem the bleeding.
After hearing an ambulance was still 15 minutes away the son got mad and hung up.
He tied his father's arm tightly in a t-shirt and drove him to the public hospital. The man was alive when he was arrived at 3.56pm and resuscitation commenced five minutes later, the report said.
"Sadly, despite a lengthy resuscitation, Mr A was pronounced deceased later that day."
The report outlined a series of errors at St John's end.
Software used in the call centre to help reduce human error classed the incident as serious but not immediately life-threatening.
That meant it met the criteria for immediate dispatch an ambulance.
St John told the commission there was initially no ambulances for dispatch, but when one became available the dispatcher sent it on a rest break.
A second ambulance was sent to a less urgent incident before one was finally dispatched to the work site, arriving at 4.32pm.
The dispatcher said he was lacking information on the situation.
There was also a call from another person on the worksite to a different operator and the two calls were logged as one job.
In her report, the commissioner said neither operator escalated the call to a clinical advisor to provide medical advice which would be expected in a call that serious.
That indicated a gap in the knowledge that went across the system, she said.
"In my view, the errors that have been identified with the call-handling represent an organisational failing for which St John is responsible rather than isolated individual errors. I consider that this highlights a need for St John to review the training and support provided to its staff in this area," she said.
She also criticised St John's internal review into the incident as being inconsistent and not reliable as evidence when assessing the care provided to the man.
The organisation had debriefed the staff members directly involved and apologised to the man's family.
The report did not canvas whether the man would have survived if an ambulance had arrived on time.
In a statement to RNZ, Hato Hone St John's acting head of clinical governance Cheryl des Landes, said it accepted the findings and welcomed the commissioner's recommendations.
"On behalf of the organisation, I would like to extend our deepest condolences to Mr A's family for their loss and offer our sincerest apology," she said.
In the four years since the incident, the organisation has made changes that included making sure high-priority incidents were routinely reviewed and escalated to clinicians where appropriated.
And it had made changes to try to reduce errors.
"We want to ensure that our patients receive timely emergency care and will review the recommendations for additional opportunities to further strengthen our systems and processes," she said.
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