The Health and Disability Commissioner has found Health NZ breached a patient’s right to services of reasonable care and skill after hours-long delays at two emergency departments on the day of a nurses’ strike. The man, identified as Mr A and aged 37 at the time, has permanently lost vision in his right eye.

Mr A experienced sudden vision loss with dizziness and nausea on 9 June 2021. An ambulance was requested at 10.25am. He arrived at Public Hospital 1’s ED at 11.24am and was triaged at 11.34am as Triage Code 2 — a category that requires treatment within 10 minutes under the Australasian Triage Scale. He was not seen by a doctor until 4.02pm.

Public Hospital 1 did not have a resident ophthalmologist. After phone advice from Public Hospital 2’s Ophthalmology Department, a locum doctor discharged Mr A for urgent ophthalmology review at Public Hospital 2 — but did not make a formal transfer-of-care or call ahead to that ED. Mr A travelled by private car with a family member.

He arrived at Public Hospital 2’s ED at 6.38pm and was triaged at 6.50pm as Triage Code 3 (to be seen within 30 minutes). He was not seen until 9.23pm, when central retinal artery occlusion (CRAO) was diagnosed. Systemic steroids were trialled, but his vision did not improve.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell found Health NZ breached Right 4(1) of the Code at both hospitals. At Public Hospital 1, Mr A’s wait of more than four hours after a T2 triage was a significant delay for a time‑critical condition. At Public Hospital 2, the two‑and‑a‑half‑hour wait after a T3 triage was also unreasonable.

The decision outlines multiple systems issues on the strike day — NZNO members were on strike from 11am to 7pm and Public Hospital 1 had minimal nursing resource. Only one nurse was on duty in the ED, supported by volunteers without medical backgrounds, and the usual practice of assigning a nurse to each triaged patient did not occur. Mr A waited in an “eye room” that was not displayed prominently on the ED whiteboard, contributing to him being overlooked. The ED had multiple T2 patients and limited resources. The locum doctor was unfamiliar with local processes and did not notify the receiving ED about Mr A’s imminent arrival.

At Public Hospital 2, staff cited strike impacts on capacity, a busy department, competing acute priorities, and the fact Mr A arrived with an undifferentiated diagnosis. CRAO was considered unlikely for his age.

Health NZ acknowledged the delays and apologised. It told HDC the six-hour window for potential intervention had already passed by the time Mr A arrived at Public Hospital 2, and that CRAO outcomes are generally poor even with timely treatment; ocular massage would not have helped with the type of clot involved. Dr Caldwell said the investigation focused on whether care met accepted standards, regardless of outcome, and found the delays were unacceptable.

A Concise Event Review by Health NZ identified:

• Lack of normal ED processes during industrial action, including no assigned nurse for triaged patients
• Poor visibility of the “eye room” on the ED whiteboard
• Ongoing pressure from urgent presentations and limited resources
• Absence of a specialist ophthalmology service at Public Hospital 1, necessitating travel
• A locum unfamiliar with referral and transfer processes, and no call to alert Public Hospital 2’s ED

Recommendations include:

• Formal written apologies to Mr A
• A protocol to ensure locum doctors understand referral and transfer processes
• Updates on implementing the review’s recommendations: additional professional support during industrial action, a reconfigured ED whiteboard, development of ophthalmology emergency pathways, and a review of policies for patients transferring by private vehicle
• A review of contingency planning to ensure critical areas are appropriately resourced during industrial action

Health NZ accepted the report’s findings. HDC noted ongoing national ED capacity issues and said it is continuing to monitor and raise these with Health NZ.

An anonymised version of the report will be sent to the Health Quality and Safety Commission and the Ministry of Health, and published on the HDC website. Names have been removed to protect privacy.