Under-staffing at Rotorua Hospital is being linked to the death of a Rotorua woman.
Sian Strutt was 27 when she died of severe sepsis, or blood poisoning, on New Year's Day 2006. Her family believe she had "no chance at all" because of the standard of care she received.
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Coroner's inquest which started in Rotorua yesterday heard Ms Strutt was admitted to hospital under urgency after going to Lakes Primecare on New Year's Eve with abdominal pain and early signs of shock.
Issues regarding her treatment and hospital under-resourcing over the holiday period were raised during the hearing, which is expected to take two to three days.
Representing the Strutt family, Jonathan Temm told Coroner Wallace Bain that health officials said Ms Strutt had already developed severe sepsis when she was admitted to hospital.
Mr Temm said urgent cases needed antibiotics and finding the cause of infection. Surgery was also appropriate.
Ms Strutt died from sepsis as a result of acute pelvic inflammatory disease.
She was not diagnosed with severe sepsis on admission and there was no record of antibiotics being given to her while she was in the emergency department, Mr Temm said.
The on-duty surgical registrar initially diagnosed Ms Strutt with pelvic inflammatory disease, pelvic peritonitis and possibly sialoangitis. Appendicitis was also considered a possibility.
An abdominal x-ray was done but no ultrasound or scan. Mr Temm said an ultrasound would have helped diagnose gynaecological problems.
There was no portable ultrasound machine in the emergency department and no radiologists working at the time.
Ms Strutt underwent laporoscopic surgery where small incisions were made in the abdomen, carried out by Dr David Vernon. Ms Strutt had also consented to undergoing a laparotomy - a bigger surgical procedure involving an incision through the abdominal wall to gain access into the abdominal cavity.
Mr Temm said the family conceded Ms Strutt might not have survived with the best care but had concerns about her treatment.
"The standard of care she did receive gave her no chance at all," Mr Temm said.
The family hoped reccommendations about hospital care would be made.
Dr Vernon told the hearing he was confident performing the surgery and was advised by Dr Abel Steyn, who was the on-call gynaecologist and obstetrician the day and appeared briefly during the procedure.
Dr Vernon said Ms Strutt was later transferred to intensive care because of deteriorating health.
"It's of course a tragedy that this has occurred but we are unable to establish whether any other things could've been done differently," he said.
The severity of Ms Strutt's condition wasn't recognised when she first arrived at the emergency department. If it had been, more drugs would have been administered.
"With the benefit of hindsight, I would have changed that," Dr Vernon said.
He was asked about staffing levels at the hospital that day.
One one general surgical registrar was working as it was a Saturday and the lack of registrars meant Ms Strutt had to wait 75 minutes before seeing a registrar after arriving.
* The inquest continues today.