Mr Fake formally apologised to the family, and agreed that Wellington Free Ambulance did not fully understand the arrangement of alarms at this property and that caused a delay in care for Mrs Smith.

“We are extremely sorry for the heartache this has caused for the family,” Paul Fake says.

“Patient care and safety is the most important thing to us, and we have certainly learned from this experience.

“We work closely with Freedom Medical who have since introduced new technology to identify who the alarm pendant belongs to when there is more than one at a single property.

“We have also updated our own policies and procedures to ensure staff always check on all people at the property where there is more than one client registered to the alarm, and all relevant staff are trained in this,” Paul Fake says.

The Coroner is expected to release her report in February.