"Clearly, with six physical beds in the main area and two side small side rooms it could not accommodate the number of HDU beds necessary for a comprehensive service."
HDU refers to a high-dependency unit for patients who fall short of needing the critical support intensive care provides, but are still seriously ill. Palmerston North doesn't have such a unit.
In a statement this week, Te Whatu Ora MidCentral district director Dr Jeff Brown said a refurbished eight-bed intensive care/high-dependency unit was expected to be fully staffed by mid-2023.
However, a new acute services facility at the hospital was further away, although planning had begun.
"It will result in a significantly expanded emergency department, theatres and critical care capacity, together with additional beds needed to support patient services," Brown said.
"Work continues over the next year focused on defining those needs and preparing the business case for the required funding.
"Once funding is approved, it is expected to take up to seven years to complete."
The 2012 "service credentialling report" found the space per bed smaller than recommended, and when full the unit's working space was "severely compromised".
Its location on the hospital's fifth floor was an impediment, because of its distance from the emergency department, radiography and operating theatres.
The report said the hospital's unit was one of the first to open in New Zealand, but by the time reports were written in 2005 and 2007, it was lagging behind other areas for the numbers of beds compared with the population.
It was still behind in a beds-to-population ratio in 2012, with about 2.5 per 100,000 people. The national guideline was for about 4.2 per 100,000.
The report described a previous unsuccessful effort to set up a high-dependency unit.
"The provision of care to this group of patients has long been a source of anxiety to staff and management at MidCentral and has been discussed and debated in many forums, and by more than one working party."
Patients were managed in an ad-hoc manner, and because in 2012 only four of the six beds were staffed, limited numbers of patients were admitted to the unit.
"The are two overwhelming difficulties in considering the adequacy of the unit's resources," the report said.
"Firstly, there is no clear idea of what service, currently, it is expected to provide and, secondly, there appears to be limited agreement among staff working within the unit as to what service it should seek to provide in the future."
Among observations about staffing, the report found staff felt management were "unsupportive of redevelopment, expansion, nursing needs and timely discharge of patients to wards". Management felt there was a lack of insight into the needs of the wider hospital and an unwillingness to accept patients needing high-dependency-level care.
Overall, the report found the unit delivered a high standard of care to patients.
What's happened since
The report made a list of recommendations, including regular meetings between senior unit figures, and that if a seismic survey found the unit should be moved a group is convened to discuss intensive and high-needs care and the design of a new facility.
A 2017 report released to RNZ shows all the recommendations were implemented.
Two years later another service credentialling report, previously released by MidCentral, was damning.
It said a total rebuild of the unit was the best option.
Again, concerns were raised about the number of beds compared with the then-district health board's population of about 180,000, and the unit's location.
It said facilities, especially those for isolation, were bleak, unwelcoming and poorly lit.
"The unit falls short in almost every area that it could objectively be assessed.
"Irrespective of its importance within the hospital it is surprising to me [external credentialer] that it has not been shut down on any number of mandatory grounds: health and safety, fire safety, earthquake resilience, infection control."
A family waiting area was said to be "at best limited, and more realistically a depressing and unfriendly space that lacks any real privacy".
The unit delivered a high-standard of care, but the facilities were substandard.
MidCentral said since then changes had been made to staffing, training and education for staff, a digital system for stocking and tracking medicines had been introduced, and the proposed refurbishment was in the works.
'Tragic' deaths at the unit
In February this year the pregnant woman and her child died after the delay in admission. The delay lasted several hours as her condition worsened.
The woman arrived at hospital in the early hours of the morning with signs of severe sepsis, but wasn't admitted to the unit until the early evening despite it being clear to staff she was likely critically ill.
She died later that night. Coroner Meenal Duggal is investigating.
RNZ asked if any changes had been made at the unit as a result of this.
MidCentral did not answer, but Brown had earlier described the deaths as tragic events and said recommendations out of a "comprehensive clinical review" would be implemented as a priority.
This week Brown said significant work had happened at the unit since the 2012 and 2019 reports.
It was intended the refurbished unit would open before next winter.
"The central region also received a total of $21.6 million as part of the critical care expansion project, of which Palmerston North Hospital received over $700,000.
"This will fund the additional beds and staffing, and also includes increasing the Patient at Risk nursing service to support patients requiring an escalation of care, as well as reducing demand for ICU beds. This additional staff is being recruited too."
The next service credentialling of the unit was likely in 2024.
