A simple spelling mistake may have caused the body of a man to lie undisturbed in a Wellington hospital mortuary refrigerator for two months until a strong smell led staff to check on him.
The man died of natural causes after a long illness in December 2003 and was taken to the Kenepuru Hospital mortuary at Porirua.
But it wasn't until February 2004 that an orderly and a clinical co-ordinator, trying to trace a strong smell in the hospital basement, checked the man's toe tag and saw he had been in the morgue for two months.
He was in a cool store and was "well preserved and not decomposing" and the smell was later traced to a rubbish truck leak, an incident investigation from Capital and Coast District Health Board found.
The board's report blamed Public Trust for not arranging a funeral after being notified, but Public Trust marketing and communications manager Henry Davies said yesterday that it had not originally been contacted to take care of the man's arrangements.
The man had no next-of-kin and a neighbour had contacted Public Trust only because he was a beneficiary of an estate it managed.
"Initial searches of the wills database showed that we didn't hold his will. This finding was subsequently found to be an error," said Mr Davies. "Basically there was a communication error over the spelling of his name."
In February 2005, Kenepuru Hospital contacted Public Trust, clarifying who was dead.
"At that point we moved immediately to arrange the funeral. Obviously we deeply regret the delay."
Public Trust had apologised to the man's neighbours and others who knew him.
The report said Public Trust was asked to arrange the funeral on his death and that the organisation had agreed to do so.
Mr Davies said that was not the case.
"There's no record of that correspondence or anything so [we] certainly didn't start acting as estate manager until early February."
He said Public Trust had reviewed its processes, including checking name spelling variations. He said a mix-up could happen again.
"I guess so," he said. "Clearly it was a human error in the way it was processed and there are now processes in place for doing more complete searches."
Board spokesman Michael Tull said the incident was a one-off and steps had been taken to make sure it did not happen again.
"We are not aware of anything even vaguely similar."
Among the report recommendations, bodies should not lie in a mortuary for more than five days without further steps being taken to arrange a funeral.