The widow of a man who died of a heart attack while on the Auckland District Health Board waiting list for treatment is unconvinced the board has changed enough to avoid similar occurrences.
Northlander Barry Searles, 76, slipped through the frailties of the paper-based transfer system that existed between the Northland and Auckland DHBs.
The Auckland board says these weaknesses have been rectified. But Eila Searles remains so dissatisfied with the DHB's response over her husband's death in 2009, 25 days after he was put on the semi-urgent waiting list, that she wrote to its chairman, Lester Levy, to complain of apparent "disarray and disengagement".
"If a senior cardiologist can't be bothered to obtain pivotal referral information then there is little likelihood of junior staff taking any responsibility," Mrs Searles wrote.
The cardiologist had received a faxed referral letter from Northland DHB. The letter understated the seriousness of Mr Searles' heart test results - he should have been admitted to Auckland Hospital immediately - but the faxed results print-out was too faint to read and the cardiologist did not seek a legible copy.
The Health and Disability Commissioner found fault with the Auckland DHB and mildly criticised the cardiologist and Northland DHB.
Mrs Searles said someone at Auckland DHB needed to "wake up and decide that there has to be a real change of culture, from the top down".
Auckland DHB told the Herald Northland DHB now employed four cardiologists so it was unnecessary to fax results to Auckland as they were now interpreted locally. The cardiologists knew to phone the Auckland DHB duty cardiologist about patients needing urgent transfer. "Faxing of referrals has virtually ceased but any faxes received here at Auckland DHB are now channelled via the central referrals office."
The series
Five years of hospital death rates have been made public for the first time - in the Herald. We compare health boards, investigate where lives are being lost and the battle to save them.
This week
Monday - District health boards compared, is death rate linked to healthcare quality, and how a simple checklist helps surgeons to avoid mistakes.
Tuesday - Waitemata DHB boosts heart-care capacity. A bereaved father questions medical justice.
Yesterday - Waikato DHB strives to understand its high death rate, medication safety, and a doctor's apology.
Today - Palliative care helps Auckland DHB's good performance. A widow fights for changes.
Tomorrow - Obesity skews the statistics in South Auckland. Lives saved by reduction of blood infections.
Contact us: Tell us your experience of hospital care.
Email: martin.johnston@nzherald.co.nz