A Government-ordered crackdown on surgical mesh operations failed to ensure that all surgeons were fully qualified according to recommended guidelines.
Instead, the Ministry of Health allowed former district health boards to decide for themselves whether each surgeon using mesh to treat women's childbirth injuries had to show good patient outcomes for at least two years prior to continue operating.
Some hospitals continued to allow surgeons to operate without providing that data.
The Australian guidelines, adopted by New Zealand, said the minimum requirement of two years of patient outcome data was designed to demonstrate that each surgeon "can undertake the procedure safely and efficiently".
Consumer Advocacy Alliance's Charlotte Korte said she was absolutely shocked that surgeons had not been collecting patient outcome data on urogynaecological mesh procedures.
"It is unbelievable, how on earth can our Government say they are taking this issue seriously?"
Korte - who has been advocating for mesh victims for nearly a decade - said these procedures had been suspended overseas because they were high-risk procedures.
"Someone needs to take some accountability for this."
In the four years since the ministry's 2018 warning letter - which was intended to stop further harm from surgical mesh operations - at least 38 more women have been seriously harmed by mesh and received ACC payouts of $650,000, as revealed by the Herald yesterday.
However, the total number harmed since the Government intervened was suspected to be much higher, as ACC said not all claims included an operation date - and some women didn't know they were entitled to make a treatment injury claim.
One woman who had mesh implanted into her body in July last year was a 35-year-old Taranaki mum who described to the Herald feeling like a "grater was rubbing against raw wounds" inside her vagina.
The scale of the problem emerged in 2018, when the Government launched a major inquiry into the safety of mesh with about 600 reports of Kiwi women suffering in debilitating pain, some being left unable to walk without aid and some trying to take their life as a result.
The harrowing stories sparked the ministry's then chief medical officer, Dr Andrew Simpson, to write the warning letter in October 2018.
In that letter, he told hospital chief executives: "We have asked that services assess surgeons using the Australian guidance for credentialing senior medical practitioners to undertake transvaginal mesh surgery for stress urinary incontinence (SUI)."
However, he told hospitals regarding patient outcome monitoring and reporting he would "ask the NZ work group to provide advice on this aspect".
The Herald put this to the ministry's current chief medical officer Robyn Carey, who said: "There was no order to collect PROMs (Patient Reported Outcome Measures), the request was for DHBs to assess their surgeons against the Australian guidance."
When the Herald pointed out this was part of the Australian guidance, Carey said New Zealand's credentialing framework was published in May and PROMs "where available" were part of the information surgeons needed to provide for that.
However, "PROMs were not well developed at this stage", she said.
When the Herald pushed asking why PROMs weren't ordered four years ago, Carey said there were other tools used including patient experience surveys, morbidity and mortality reviews, patient case reviews, and routine follow-ups after surgery.
"Datasets are not seen as a substitute for good medical and therapeutic practice, where there should be rapport between patient and clinician as part of the suite of care."
Back in 2018, advocates were also calling for a national registry to track women with surgical mesh.
Last month, Health Minister Andrew Little was asked by National's health spokesperson Shane Reti how many, if any, had been diagnosed with pelvic mesh-related complications per year in the past five years.
Little replied saying that level of detail had not been reported by the ministry and answering that question "is not in the public interest".
Carey said the ministry was exploring options for a registry to track the long-term safety and performance of mesh procedures.
"No decisions have been made on its form, however."
She said there was also a complaints process, where patients could voice their concerns directly to their clinician, the hospital or the Health and Disability Commission.
Many of the women the Herald has spoken to say the complaints process was flawed as cases often ended up getting closed without validation that they had been listened to or understood.
One included Sally Walker, whose bladder was removed and vagina sewn closed after mesh was implanted incorrectly, causing severe damage to her insides. Her case was closed as her surgeon had a medical condition and could not respond.
The Herald surveyed the country's main hospitals to ask them if their surgeons used PROMs and what they thought of them, which showed serious inconsistencies.
At Auckland City Hospital, chief medical officer Dr Margaret Wilsher said they recognised the value of PROMs but they didn't collect them.
"We're looking forward to receiving advice from the national working group on which PROMs tool to implement as part of the upcoming New Zealand framework," Wilsher said.
At Waitematā, a spokesperson released a statement saying: "We prioritise patient safety, and PROMs are an important element in assessing the safety and efficacy of clinical practice in urogynaecological surgeries involving mesh."
The North and West Auckland hospitals collected PROMs and questions were currently being refined with consumer input to optimise their value, they said.
Capital and Coast and Hutt Valley's interim district director John Tait said PROMs were not routinely recorded for urogynaecology surgery involving mesh prior to 2018.
However, Tait said they were implemented as an "additional measure" to assist with monitoring and quality assessment.
"Demand for these procedures in our district is low and two of our credentialed Wellington gynaecologists perform them together, wherever possible, both in private and public to maintain competence and observe practice," Tait said.
Canterbury's clinical director urology Giovanni Losco said they did use PROMs and saw it was an "effective way to ensure patient safety as they can be used to measure the success of treatment and quality of care and life from the patient's perspective".
A Middlemore Hospital spokesperson said "the scope of urology surgery at CM (Counties Manukau) does not include interventions that require use of mesh.
Some hospitals - like Northland- stopped mesh surgeries altogether because they couldn't ensure their surgeons had the appropriate skills to perform the operations.
Waikato Hospital was recording PROMs prior to 2018 and continued to do so.
A Southern spokesperson said they couldn't answer in the timeframe given and instead put the Herald's request through the Official Information Act which meant they had 20 working days to respond.
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Banks are to benefit from the controversial decision.