Managers at the Southern District Health Board were aware for around three years of issues with its urology service causing long delays in treatment, a Health and Disability Commissioner report has found.
The report, a piece of work instigated by the commissioner after having received multiple complaints about the service, noted that the HDC office had heard from 38 patients in total and considered four cases in particular.
"Southern DHB's inadequate response failed each of the patients discussed in this report,'' Health and Disability Commissioner Anthony Hill said.
Mr Hill said delays in the assessment and treatment of patients posed a consequent "substantial clinical risk.''
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"When the system was unable to meet the demand, the DHB was slow to act in a way that was cohesive and would bring effective, sustainable improvement,'' the report said.
"There was little planning for urology services across the entire DHB.''
However, the commissioner did praise the SDHB for its eventual response to a situation which he said had escalated to a crisis.
"I commend the chief executive and his team for the work that has been undertaken, in particular over the last two years,'' Mr Hill said.
"The 'mega-clinic' weekends (organised to address waiting lists) are an excellent example of the clinical support and organisational commitment that has been utilised to address the challenges faced by the urology service.
"HDC will continue to monitor progress.''