A woman died in 2013 because a paramedic failed to give her enough care after he was unable to wake his co-worker, an inquiry has found.
The 69-year-old was taken to hospital after paramedics visited her for a second time in one night, with the paramedic coming alone after his volunteer crew member didn't wake up.
Deputy Health and Disability Commissioner Theo Baker said the paramedic failed to bring portable oxygen into the house, even though the patient was lacking oxygen.
A report into the case said the chair the patient was in tipped over, and she collapsed and fell to the ground.
It said the woman's daughter had to help put her mother on a stretcher and into the ambulance.
The daughter said her mother "looked at her and repeated twice I am going to die."
The report said the paramedic asked the woman to drive the ambulance but she refused; the daughter said she was never asked.
On the way to the hospital, medical alarms sounded, but the paramedic did not stop the vehicle and the patient died in the back on the ambulance.
The daughter said she was yelling at the paramedic that the red light light was flashing and there was a question mark alert but "he just kept going and didn't even stop - we were flying."
The report said the paramedic was visually assessing the patient during transport.
"He had the monitor facing forward because of the seriousness of the woman's condition... he was aware of the alarms and her condition during transport.. but stopping to treat her was not going to change the situation."
Ms Baker said the women's treatment was seriously inadequate and also criticised the unnamed ambulance service for communication failures.
All ambulance volunteer staff now work all their shifts from the station 24 hours a day.
The paramedic said he did not call for support as he did not want to put a strain on other services.
"As on many occasions, when we worked single crewed at nights during the week, weekends; and during days of the weekends, we have to get people in and out of houses and places on our own by any means possible.
"If we were to call the fire brigade, who are also volunteers, they would be put under some serious strain by responding to assist us on a very regular basis," he said.
The paramedic has been demoted to the role of an emergency medical technician.