The man was referred to the neurosurgeons the following morning. While awaiting air transfer, his condition deteriorated and, on arrival, after an MRI scan, it was found that he had a ruptured cerebral abscess.
It is unclear whether earlier consultation or transfer on the night of admission could have prevented the abscess from rupturing, given the risks of transfer.
Health and Disability Commissioner Anthony Hill found West Coast District Health Board breached the Code of Health and Disability Services Consumers' Rights by failing to ensure that its on-call physician was informed of patient transfer processes.
In addition, the board breached the code for the poor standard of clinical documentation on the man's hospital record.
"It is essential to a patient's seamless continuity of care that all clinical reviews and decisions are fully documented. The omission to do so creates potential risk,'' Mr Hill found.
The commissioner was critical of the care provided by the physician and the emergency department doctor as it related to the man's opportunity to have specialist neurosurgical advice and consideration of transfer.
Michael Frampton, programme director and acting general manager of hospital services for the West Coast District Health Board, said the DHB accepted all of the recommendations in the report.
"We did not provide an acceptable standard of care for this man, and I apologise to him and his family,'' Mr Frampton said.
"In this case there were a number of aspects of his care that were not carried out in a timely manner. These factors, in addition to unavoidable delays due to weather and aircraft mechanics, delayed his transfer to Christchurch.
A number of changes to its systems had been made in the wake of the man's case and a number of other changes were underway across the West Coast health system that were improving the safety and sustainability of services, Mr Frampton said.
