AMBULANCE bosses admit a series of blunders may have contributed to the death of World War II digger Bob Mutton and have apologised to his family.

An investigation into the circumstances surrounding the Changi prison camp survivor's death found a series of "operational deficiencies", including an unacceptable response time.

Staff involved will be officially counselled.

The inquiry was launched after an exclusive report in The Cairns Post revealed Mr Mutton waited more than two hours for an ambulance.

Releasing the outcome of the investigation yesterday, Queensland Ambulance Service deputy commissioner Russell Bowles told The Weekend Post: "It is very unfortunate and I am sorry that it happened and my heartfelt condolences go out to Mr Mutton's family."

On the day Mr Mutton died in late July, it took almost an hour for the first ambulance to be dispatched to his Cairns home after his doctor called to report the 88-year-old was struggling for breath.

That ambulance was diverted four minutes into the job. After another 71 minutes, an ambulance arrived from Kuranda before taking him to Cairns Base Hospital where he later died.

At the time, ambulance bosses blamed delays in reaching the war veteran on the number of ambulances delivering patients to Cairns Base Hospital.

But the investigation found crews were in fact available to respond to Mr Mutton.

The investigation found the initial call was classified correctly but it was not actioned correctly.

It also found there was an unacceptable initial response time and diversion, and that standard procedures were not followed when responding to calls made by Mr Mutton's doctor.

"Standard operating procedure required a response to this case within 20 minutes," Mr Bowles said.

"This did not occur as it took paramedics two hours and five minutes to respond.’’

Mr Bowles added: "While some crews were waiting to admit patients at CBH, there were other resources available that should have been redirected.

"Mr Mutton's case was urgent enough to require the attendance of one of those crews."

Mr Bowles said while some of the staff involved had been debriefed on the incident, others would soon be and they would be "officially counselled regarding this matter’’.

"We are human. We do 60,000 cases a year and now what we have to do as these cases come up is - and we don't always get it as right as we want - is not to have a witch-hunt," he said.

Mr Bowles said as a result of the incident he had also directed the assistant commissioner Peter Cahill to reiterate to all staff the importance of following QAS policy and procedures.

He said the QAS was trying to contact Mr Mutton's family to take them step-by-step through what happened on that fateful day.

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