A 73-year-old man deteriorated and died after delays in the provision of care at a Northland public hospital in 2014.
In a report today, Health and Disability Commissioner Anthony Hill told the Northland District Health Board to apologise to the man's family and make changes to improve care.
He said the man, Mr B, had complex health conditions and had been admitted to hospital after a month of diarrhoea and abdominal pain. Mr B returned less than a week after being discharged however, and was admitted to the Emergency Department, which was extremely busy that day, and the subject of a Code Orange alert.
Mr B waited 35 minutes for triage at the ED. A nurse ordered tests, including one that indicated heart damage, but the result was not conveyed to Mr B's doctor or the other registrar.
Mr B was transferred out of the ED to a ward for patients with lower need so the hospital could meet the Health Ministry's health target governing the time spent by patients in the ED, which must not exceed six hours. Mr Hill said a report by the DHB indicated this move "was not in the best interests of Mr B".
He adds the move to another ward occurred without important interventions, including the insertion of a catheter, having been done. Antibiotics and medical review by doctors were also delayed by the move.
By mid-afternoon on the day Mr B was admitted, he received the review by doctors on the surgical ward, four-and-a-half hours after it was requested by Mr B's doctor.
By then, doctors had also received blood test results and were aware of the likelihood that Mr B had inflammation in the inner lining of his heart.
Mr B then began feeling cold and started shivering. He continued to deteriorate and died of inflammation of the inner layer of the heart.
Mr Hill said Mr B had complex medical conditions. Nevertheless, he said there were warning signs during Mr B's first hospital admission, including his low blood pressure and varying temperatures.
He said there were opportunities for further inquiry and they were missed.
He was also concerned at the delays during Mr B's second admission to hospital. He said the DHB failed to provide services with reasonable care and skill and breached patient rights as a result.
He urged the DHB to make changes, including auditing the effectiveness of its new triage process, reviewing its severe sepsis management policy and developing a clear policy as to who had responsibility for following up test results ordered by ED-registered nurses.
Mr Hill said the DHB had made improvements, however.
"So there have been material changes implemented already, both in relation to their processes, availability of staff and the protocols that they follow."
He added he has asked it to undertake more work on other policies as well, and the DHB would report back on those in the next few months.
The DHB did not respond to RNZ's requests for comment.