Health Minister David Cunliffe says he accepts a critical report from the Health and Disability Commissioner on patient referrals.
The report found three patients needing urgent treatment had serious setbacks after their medical referrals were lost between district health boards.
One patient lost an eye, one had a serious stroke and the third had prostate cancer spread to his bones after his examination was delayed by months.
Health and Disability Commissioner Ron Paterson has investigated the cases, and his report was today made public.
He has called for the district health boards involved to apologise and overhaul their systems.
Each case involved an avoidable delay caused by the boards' ineffective referral systems or poor communication, Mr Paterson said.
Mr Cunliffe today said he accepted the report and agreed with Mr Paterson's conclusions.
"There is no excuse for the lapses identified by the Health and Disability Commissioner in the three cases involved and I extend my sincerest condolences to the families concerned."
He said the report's findings reflected work already being undertaken to improve quality and build safer systems across the health sector.
But National's health spokesman Tony Ryall said the Government had been too slow to act.
"Labour has spent millions of dollars on various health IT projects and bureaucrats, but it still can't keep track of important letters from GPs and other hospitals.
"This is basic stuff. If hospitals can't communicate with each other effectively, then the system breaks down and patients suffer."
He said the cases in the report were the tip of the iceberg.
The three cases happened in 2006 and last year.
Each patient's condition was analysed by their own doctor or health board, and they had been told they needed urgent treatment.
They had to be seen by different public hospitals, and letters were written to these institutions detailing the patients' needs.
But in each case, the patient did not get the treatment required.
New Zealand has 21 district health boards, but not all have the facilities to help patients with complex conditions.
For example, only five boards have hospitals doing cardiac surgery, meaning a heart patient in one of the other 16 boards' areas must be transferred to a cardiac surgery-capable hospital to get the care they require.
Mr Paterson's report severely criticises the communication between boards when dealing with such referrals. It calls for apologies, reviews and a centrally driven solution to the problem.
Mr Paterson said the cases highlighted the need for a consistent, co-ordinated national system for handling referrals.
"Whatever referral system is operating between district health boards, it has to work for patients."
His recommendations include:
* That the Northland, Auckland, Counties Manukau, MidCentral and Capital and Coast district health boards review their referral systems, reporting back to him by January 31.
* That MidCentral DHB and an unnamed GP clinic apologise to their patients.
* That the Ministry of Health review the inter-board referral system, and report back to him by January 31.
* That the Director-General of Health, Stephen McKernan, advise by March 31 what action has been taken to fix the problems.
The Ministry of Health's principal medical adviser, Dr David Galler, said it was clear current systems had failed the patients, "and that's simply not acceptable". The ministry would, in the short term, talk to the boards to identify gaps in their referral systems and to standardise the systems.
Electronic referrals would be progressively introduced from next June.
The health boards involved said yesterday that they were sorry for the incidents and had apologised to the patients and their families or were in the process of doing so.
They said the systems that had contributed to the mistakes were being reviewed and overhauled.
* The cases
Patient 1 - Aug 2006: A suspected retinal detachment in Whangarei is referred to specialists at Auckland DHB.
Ten days later: No word from Auckland; patient asks Whangarei doctor to follow up. Auckland confirm they have the referral.
Feb 2007: Still no action from Auckland. Patient again asks doctor what is happening. By then the condition has worsened too much for the treatment.
Nov 2007: Patient's left eye is removed.
Patient 2 - Aug 2006: Patient found to have narrowing of arteries after a minor stroke.
Dec 2006: MidCentral DHB (Palmerston North) surgeon refers patient to a specialist at Capital and Coast DHB.
Oct 2007: Patient asks for update, discovers Capital and Coast has no record of the referral. Another referral made.
Nov 2007: Capital and Coast DHB has no record of second referral. Patient has a second, more serious stroke.
Patient 3 - May 2007: Patient discovers blood in his urine, tells GP. Tests indicate possibility of prostate cancer. Patient is referred to Counties Manukau DHB.
The health board misplaces the referral.
Six weeks after the referral was sent it is actioned. Patient prioritised as needing review in four to six weeks.
Oct 2007: Only after GP asks health board why nothing has happened is the patient reviewed. He is diagnosed with prostate cancer. It had already spread to his bone.
- With NZPABy Craig Borley Email Craig