Paramedics arrived to treat Toronto businessman James Hearst 35 minutes after the first 911 calls were made. (CBC)

The Ontario Ministry of Health says there was a preventable delay in the response time by Toronto paramedics to an ailing man who died waiting for medical attention.

The ministry released a report Thursday on its investigation into the response to 911 calls placed shortly after James Hearst, 59, collapsed after suffering a heart attack.

It took 38 minutes for EMS workers to arrive and treat Hearst, who collapsed in the lobby of his apartment building at 40 Alexander St., near Church and Wellesley streets, on June 25, three days into the civic workers strike. By that time, he was dead.

Bruce Farr, chief of Toronto Emergency Medical Services, said at a news conference Thursday that the delays occurred because of a series of decisions made by five people who responded to the 911 calls, not because of larger protocol issues.

Emergency services operated at 75 per cent capacity during the strike, but Farr said Thursday this had nothing to do with the delayed response.

"My deepest sympathies are extended to Mr. Hearst’s family on behalf of the entire Toronto EMS team," he said. "I want to assure the family and all Torontonians that we have learned from what transpired and will take action to strengthen existing policies and procedures so that this situation can be prevented in the future."

As a disciplinary action, the two paramedics, two dispatchers and one supervisor will have to take 10 to 17 days of unpaid leave, he said. They also face probationary monitoring for up to a year after they return to work.

The investigation found they did not follow procedures established by EMS.

Although Farr acknowledged the delay could have been avoided, when asked by a reporter if Hearst's death was preventable, he responded: "We'll never know."

"I wish I had the opportunity to have my medics there with him."

Hearst's partner of eight years, Alejandro Martinez-Ramirez, said Thursday the disciplinary action taken against those involved "is really a joke."

Waited because of safety fears

The report outlines the sequence of events that led to Hearst's death.

A man in Hearst's building first called 911 at 11:04 p.m. to say a man who collapsed in the lobby was trying to get up.

"He looks like he might be drunk," the caller said, adding Hearst had a gash on his head.

Paramedics arrived at the scene at about 11:14 p.m., the report said. They drove down the street to the intersection of Yonge and Alexander streets and parked there while Hearst lay inside his building.

The dispatcher had told the paramedics the man might be drunk so, out of fear for their safety, they waited for police to arrive before entering.

Farr confirmed that if paramedics feel that there's danger at the scene, EMS policy states "they do not need to enter until police get there. However, they need to go to the scene and confirm that's the case. They can't sit down the street and wonder."

The paramedics should have moved to the front of the building and parked outside if possible, Farr said, so the callers could see emergency personnel were on hand.

A security guard at the building called the dispatcher at 11:19 p.m. to ask where the paramedics were. He said he was concerned because Hearst was turning blue and bleeding from the nose.

Toronto police weren't assigned to the call until 11:35 p.m., 21 minutes after paramedics first arrived, the report said. At this point, Hearst was still conscious and breathing.

At 11:36 p.m., someone called the dispatcher to say Hearst was no longer breathing. The priority of the case was upgraded, but paramedics told the dispatcher at 11:38 p.m. that they still did not feel safe entering.

Another ambulance arrived at the scene at 11:43 p.m. to attend to Hearst. He was pronounced dead at 12:07 a.m.

Miller apologizes

Mayor David Miller offered his condolences to Hearst's family.

"The events of June 25 were wrong," Miller said.

"While Toronto EMS provides an exceptional service to our residents 24 hours a day, seven days a week, it is clear that on this particular day our system did not function as it should. And for that I apologize on behalf of City Council and the Toronto Public Service."

Thursday's report contained 13 recommendations for Toronto EMS, largely concerning a review of current policy and additional training.

Farr said some of the recommendations have already been implemented, including:

• The preparation of new training programs.
• A review of training policy.
• Improved oversight of the response process.