A 73-year-old man with heart damage was transferred to a surgical ward before he had been reviewed by a doctor in order to meet the emergency department's six-hour target.
Health and Disability Commissioner Anthony Hill found Northland District Health Board failed to treat the man with reasonable skill and care.
The man was admitted to hospital after having diarrhoea and abdominal pain for four weeks but doctors discharged him because they believed his symptoms were from the drug he had been taking for gout.
He was scheduled for an urgent colonoscopy to make sure there were no other issues.
A week later he returned to hospital, still unwell but because it was a particularly busy time of day it took 35 minutes for him to be triaged.
A nurse took a blood sample and sent it off for testing. The Troponin T test indicated heart damage but the registrar was not advised of the results via telephone.
A decision was made without the knowledge of the surgical registrar to move the man to a ward and because the emergency department was so busy he did not have a catheter inserted or a fluid balance chart started as was normal process.
A medical review and antibiotic administration were also delayed.
Shortly after review by an intensive care registrar, the man advised nursing staff he was cold. A blanket was provided, and antibiotics were administered.
The man continued to deteriorate and died, despite attempts to resuscitate him.
Hill said further tests should have been carried out the first time he was admitted to hospital and was critical staff did not do so. He said medical or cardiology input, a CT scan and consideration of the source of the infection would have been helpful.
Hill acknowledged the emergency department was busier than usual on his second admission but was critical the high Troponin T result was not telephoned to the registrar, there was no on-call physician available to help while busy and that the man was moved to a low acuity ward without discussion or treatment just to meet a target.
Northland DHB noted at a mortality and morbidity meeting that the man was transferred to meet the six-hour emergency department target and that it was not in his best interests.
Hill recommended the DHB audit aspects of the effectiveness of its new triage process, review its sepsis management policy, develop a clear policy for following up test results ordered by emergency department nurses, review the emergency department's standard operating procedure, review the role of on-call consultants to ensure that adequate supervision of junior doctors is occurring, and remind all staff that the transfer and the location the patient is transferred to must be clinically appropriate.