Waikato Hospital is so understaffed it only has two junior doctors covering an entire medical unit of 290 beds across 12 wards at night.
Alarm at the overnight staffing shortage and that 419 resident doctors at the hospital are stressed with overwork, can't take leave, and aren't getting enough supervision, was raised by a union almost three months ago.
Now Waikato District Health Board is being warned by the Medical Council of New Zealand over its intern training of house surgeons and registrars, and has six months to improve or face losing accreditation.
A three-yearly review of the DHB's training of interns by the Medical Council in early August found the DHB did not meet four of 22 sets of standards.
The four failed standards were around:
• Training-programme governance
• Medical workload issues
• Clinical task management
• Intern welfare and education resources.
The DHB is already working to regain accreditation in obstetrics and gynaecology and is on notice over its accreditation in orthopaedics. Without accreditation interning doctors leave to train at other hospitals.
New Zealand Resident Doctors Association general secretary Deborah Powell said serious concerns about workloads, access to and cover for annual leave, a lack of supervision by busy senior doctors and serious understaffing, particularly in the emergency department and medicine, were flagged with the DHB in July.
"These doctors are stressed out of their minds. Their psychological and physiological welfare is at risk and through that the patients as well.
"You can't sustain an ongoing increase in workload without a matching of staff especially when it's hands-on medical care delivery."
The union sent several letters raising concerns, initially to chief executive Dr Nigel Murray, who went on leave on July 22 while his expenses are investigated.
But when Powell spoke with senior DHB executives last week they were not fully aware of the situation.
"We've got a cultural issue. How did the executive management team not know? These are massive risks and how can you manage a risk if you don't know you have one?"
The Medical Council required that the ratio of supervising doctors increase to 1-to-10 and the DHB agreed to a second house surgeon to cover the medical wards at night though Powell believes it should be at three or four, especially at Waikato Hospital where the 12 wards are spread across the campus.
Women's Health commissioner Tanya Maloney, now leading the project to keep the accreditation, said there was not a disproportionate number of clinical incidents or deterioration happening on night shifts that would have indicated a problem.
"I'm not understating the concern or the urgency that needs to be taken to address the problems, however I am saying now that we know we've taken action really quickly."
Maloney would not specify the 12 actions required by the Medical Council but said the DHB was urgently working to address the four failed standards.
That included adding a second house surgeon to cover night shifts in Medicine, recruiting more senior doctors internally to act as training supervisors, improving access to leave, improving governance, reminding doctors about a counselling service, and trialling an electronic task management system for doctors from next April.
Maloney admitted leave access had been raised and that it should have been acted on quicker but said many of the other issues were a "surprise" to managers.
"There is a process of addressing them and we haven't done that quickly enough and we certainly will ensure that happens."
Maloney said she was concerned for the welfare of doctors but not worried about patient safety because that was not compromised.
She pointed out that the lone overnight house surgeon was currently supported by a registrar, a slightly more experienced doctor.
The Medical Council report would be made public in a month and the DHB training will be reviewed again in six months.
Auckland and Southern DHBs lost accreditation from intensive care departments in 2014 and 2015 respectively. Southern DHB also lost its orthopaedic training accreditation that year.