A coroner is urging the country's district health boards to review their transfer procedures after he found there were undue delays in transferring a critically ill Christchurch man to a public hospital.
The death of Ian Chauncey Bell, 72 was assessed by the coroner after "a number" of concerns were raised by his family, including wife Julie, following care he received after surgery at Southern Cross Hospital and his ultimate transfer to Christchurch Hospital when a complication was discovered.
Bell, described by his wife as a passionate rugby supporter with extensive equestrian farm and equestrian skills, was admitted to Southern Cross Christchurch hospital for an elective robotic radical prostatectomy to treat early prostate cancer on November 1, 2017.
He was returned to his ward in a stable condition but soon became uncomfortable and had low blood pressure.
When checked by his surgeon at 2.55am the following day, Bell was thought to be experiencing bladder spasms. He was given medication and stabilised.
At a surgical review at 6pm, it was decided Bell would be transferred to the urology ward at Christchurch Hospital for observation. However, the surgeon noted that if Bell deteriorated, a CT scan should be organised.
On arrival at Christchurch Hospital, the urology registrar was concerned about Bell's condition and admitted him to the Intensive Care Unit at 11.40pm with a presumptive diagnosis of sepsis.
A CT scan early on November 3 revealed a bowel perforation and during surgery bowel contents were discovered "throughout the abdomen".
Bell continued to deteriorate and he died on the afternoon of November 4 from sepsis.
Listing her concerns, Julie Bell queried why her husband's bowel perforation and septicaemia were not discovered earlier, despite his deteriorating condition; why there was a delay in getting a CT scan and sending him to the urology ward.
In his decision, Coroner David Robinson found issues with the transferring of patients from private to public hospitals as Bell deteriorated "right in that window of transfer", which saw a breakdown in communication from surgeons involved.
An ambulance was called at 6.57pm but didn't arrive at Southern Cross until 8.13pm and Christchurch Hospital at 8.24pm.
Bell was originally not seen as a priority one patient but the nurse waiting with him noted he was deteriorating and the ambulance was given a new RED response.
However, staff in the ambulance were unaware of his notes and assumed there was no need to carry out monitoring nor were they asked to.
They were also not advised that he was in such a critical state.
Given what happened during his care, Coroner Robinson issued a recommendation that the Ministry of Health be provided with the Transfer of Private Patients to Christchurch Hospital policy and encouraged other district health boards to develop similar policies.
He also requested his finding be sent to the Urological Society of Australia and New Zealand for its members, with a particular focus on those who have robotic assisted prostatectomy and their progress to recovery.
Southern Cross Hospital has since reviewed its transfer policies so that they now align with that of Canterbury District Health Board.