You are not permitted to download, save or email this image. Visit image gallery to purchase the image.

Southland Hospital. PHOTO: ODT FILES Doctors in Southland Hospital’s emergency department were so swamped with patients it meant a man’s dangerous infection was not treated sooner, the health and disability commissioner has found.

The patient, referred to as "Mr A", had the bad fortune to arrive at Southland Hospital on March 10, 2019, just as the facility was about to experience a bed block crisis.

Mr A was meant to be admitted to the orthopaedic department with back pain, but as that ward was full he was kept in the emergency department to wait for a bed to become free.

However, the orthopaedic ward remained at capacity and by the following evening all the Southland’s emergency department beds were also full, as were the beds in the corridor outside which are only used in dire situations.

While Mr A languished he developed an infection and his blood pressure dropped worryingly.

Deputy commissioner Deborah James said that because of confusion between emergency and orthopaedic staff about who was actually looking after the patient his condition continued to deteriorate.

Mr A’s blood pressure was not adequately monitored, antibiotics were not administered as soon as they could have been, his urine was not tested, and usual medications were withheld.

Staff also had difficulty finding Mr A’s observation chart to appropriately monitor him.

"When a patient is being seen by different teams during the course of a hospital admission, it is essential clear and effective communication occurs between all teams involved, and the Southern District Health Board should have in place formal policies and processes to optimise care," Ms James said.

"It is SDHB’s responsibility to provide clear guidelines to its staff and ensure they understand the areas of clinical presentation for which they are responsible."

Although critical of some staff, and also making adverse comment about one of the orthopaedic doctors who cared for Mr A, Ms James accepted that Southland Hospital was overloaded at the time and was a challenging work environment for clinicians.

Several of the misfortunes in the care of Mr A — who has since died — were likely the result of a "dysfunctional/overloaded" hospital and were systemic rather than individual failures, she said.

In September the following year then chief medical officer Nigel Millar proposed that the SDHB adopt an "escalation plan" to attempt to forewarn of looming bed block issues.

The top tier of that alert system, code black, was briefly reached at Dunedin Hospital in March 2021.

Southern hospitals are understood to have regularly reached the second tier, code red, in recent weeks due to the impact of severe winter illness and the number of patients arriving at hospital who also had Covid-19.

Te Whatu Ora Southern quality and clinical governance solutions director Hywel Lloyd said that the organisation fully accepted the commissioner’s findings and had already made changes to its systems and processes.

"We have changed our system for storing observation charts in Southland Hospital’s emergency department, to ensure staff from other departments have fast and easy access to patient records of vital signs for the duration of their visit," Dr Lloyd said.

"Te Whatu Ora Southern has extended its sincere apologies to the man’s whanau for our failures in this case."

mike.houlahan@odt.co.nz

We are the South's eyes and ears in crucial council meetings, at court hearings, on the sidelines of sporting events and on the frontline of breaking news.

As our region faces uncharted waters in the wake of a global pandemic, Otago Daily Times continues to bring you local stories that matter.

We employ local journalists and photographers to tell your stories, as other outlets cut local coverage in favour of stories told out of Auckland, Wellington and Christchurch.

You can help us continue to bring you local news you can trust by becoming a supporter.