A man died while waiting on Auckland City Hospital's semi-urgent heart waiting list after a faxed test result was too faint to read and no request was made for a legible copy.

The case, reported yesterday by Health and Disability Commissioner Anthony Hill, has echoes of the 2004 death of Mervin McAlpine, 82, after the hospital mixed a fax from his GP giving details of his medication with those of another patient.

As a result Mr McAlpine received a fatal combination of the wrong drugs.

In the later case, in which the patient is not named, Mr Hill has criticised the Auckland District Health Board for failing to have an effective system to ensure that the priority ranking of heart patients from another DHB (not named) was done properly.


The man saw his GP in July 2009, complaining of chest pain on exertion. An exercise test at the un-named "DHB 2" indicated he had "significant coronary artery disease that required urgent attention".

One doctor reported the man's exercise stress test results were "grossly abnormal", but in the referral letter to Auckland City Hospital's cardiology department, the result was described as "positive".

The test result, printed on pink paper, was faxed - with the referral letter - to the hospital but came out too faint for the triaging cardiologist to read.

The referring DHB said the fax was sent on July 29, 2009, and Auckland City Hospital said it received it on July 31, 2009.

The man, "Mr A", was assigned to the semi-urgent waiting list and given appointment dates of August 31 or September 2, although the waiting time on the urgent list at the time was longer than that, at six weeks.

Mr A died in August 2009 of a heart attack.

The Auckland City Hospital cardiologist who assigned Mr A as semi-urgent told the commissioner that it was exceptional for the referring doctor not to have drawn attention in his letter to the "strongly positive nature" of the exercise stress test result.

If "full information" had been provided, "any triaging consultant would likely have recommended direct admission without putting [Mr A] on any waiting list", the cardiologist said.

Mr Hill made "adverse comment" on the cardiologist - saying he should have arranged for the illegible information to be followed up - and on the referring DHB, which he said should have had a system to ensure its referral had been received and that Mr A was being seen promptly.

His recommendations included that Auckland DHB tell referrers it expected them to phone the on-call consultant - as well as making a written request - when referring urgent or high-risk patients.

DHB 2 officials told the commissioner of changes that had been made, including encouraging doctors to photocopy the pink exercise test results on to white paper for faxing.

Auckland DHB officials told Mr Hill a regional electronic referral system was being developed that would reduce the likelihood the board would fail to follow up of documents were illegible.

A spokesman for the Auckland DHB said last night the board was doing all it could to implement Mr Hill's recommendations.