St John is being asked to apologise to a woman who was transported to the wrong hospital.
A report released today by the Health and Disability Commissioner, Anthony Hill, said St John sent the woman, who had a ischemic leg, to a local hospital in 2015, even though her GP asked for her to be sent to a main centre hospital.
Ischemia is a reduction in blood supply to a part of the body.
Mr Hill said he was now asking the ambulance service to apologise to the woman and review its policies.
The names of the hospitals were not given.