A woman was presumed dead and left in a car's wreckage with a tarp over her body for an hour after a paramedic failed to check her pulse, officials said.

A medical examiner discovered the woman was breathing and equipment was rushed to the scene that could remove her from the wreckage, officials said. Erica N. Smith, 23, died the next day.

She had suffered a severe head injury, and officials said the paramedic had judged Smith to be dead by looking at her, a violation of city policy to check vital signs regardless of injury.

Such a checking "is part of the protocol, and it's part of the protocol for a reason: To save lives," City Attorney Michael Bernard told the San Antonio Express-News.

Fire Chief Charles Hood said "medical protocol was definitely violated in this instance. It was an error in judgment."

"I'm sorry for what the Smith family has endured, and I'm sorry for the mistake that was made on our part for the incident," Hood said.

The chief initially defended the department's response to the Dec. 16 crash, saying paramedics were unable to find Smith's pulse and he didn't expect anyone to be disciplined.

"We were assuming (they had checked for her pulse)," Hood said Tuesday.

Smith's relatives said they're still upset with the city's handling of the incident.

"I'm very angry," said her father, Robert Smith. "It's a struggle, minute by minute."

Officials said the paramedic responsible, Mike Gardner, 35, has been transferred to the Fire Department's firefighting division and permanently restricted from working as a paramedic in San Antonio.

Three other paramedics who responded to the wreck were demoted and stripped of their licenses to practice emergency care in the city, officials said.

Hood said the four paramedics were in the 21st hour of a 24-hour shift that began the previous day.

Chris Steele, head of the San Antonio Professional Firefighters' Association, said the four paramedics met with Hood on Monday and were aware of the disciplinary measures. He said the case had exhausted them to the point that they're "pretty much not emotional anymore."

City Manager Sheryl Sculley said the city would immediately implement more training as a result of the mistake.

The Associated Press left a message for Gardner on Wednesday with the union. A message left for a Michael Gardner in San Antonio at a number from an online phone book listing was not immediately returned.

Smith, a senior at Texas State University, was the front passenger in a Honda Accord that was struck head-on by another vehicle that crossed the median on Loop 410, police said.

While Smith was left unattended, the paramedics took two other people in the Accord to the hospital with serious but non-life-threatening injuries.

The driver of the other vehicle has been charged with intoxication manslaughter, police said.