A 55-year-old man with burning chest pain and a family history of heart attacks had to wait five hours in an overrun and understaffed emergency department before finding out he was in cardiac arrest.

Now, nearly three years on, the Health and Disability Commissioner (HDC) has ruled Health New Zealand did not provide the man with an “appropriate standard of care”.

In a decision released today, Commissioner Morag McDowell said the man’s symptoms, age, gender, Māori ethnicity and family history should have raised “immediate suspicion”.

McDowell said it was just after midnight in August 2023 that the man entered Wellington Regional Hospital’s emergency department.

He was seen by one of the department’s nurses after 15 minutes.

The nurse’s assessment noted that the man had experienced three hours of chest pain radiating out onto his left shoulder, which didn’t get better despite him taking an antacid.

His pain was a 7/10 and the man was noted down as having a family history of heart attacks.

He had elevated blood pressure but his other vital signs were normal and the nurse gave him a “triage score” of 3, meaning he was to be seen by a doctor within 30 minutes.

He was not seen by a doctor, however, for four-and-a-half hours and just after 5am an electrocardiogram (ECG) showed he was having a heart attack.

He was “urgently” sent to the cardiac team who installed a stent to open one of his arteries and improve blood flow to the heart.

An adverse event report (AER) by Health NZ showed the nurse hadn’t thought it likely the man, who also had been experiencing stomach issues in the days before, was suffering from a heart attack.

The report also found that the man should have been given a triage score of 2: to be seen in 10 minutes.

Health NZ’s assessment continued to explain that at the time the man appeared in hospital, its emergency department was at 200% occupancy and was down 10 nurses for that shift.

McDowell said although it was important to note the bias of “hindsight,” it was clear the man was having symptoms of a “cardiac nature” that should have required an ECG during that first assessment.

She said the man’s symptoms and history being wrongfully assessed caused him to be seen by a doctor “well outside” the appropriate timeframes.

Therefore, Health NZ breached the HDC’s code of rights by not treating the man with “reasonable care and skill”.

Health NZ has offered its “sincere apologies” to the man and remedied the situation by taking steps to better educate ED nurses on cardiac events and symptoms.

It was also making a hospital-wide response plan for when the ED is at “critical capacity”.

The decision also said the Government announced this year investment to upgrade Wellington Hospital’s ED.

McDowell recommended that Health NZ Capital, Coast and Hutt Valley audit their last 30 cardiac ED patients and check their triage score was appropriate.

She also ordered updates on the hospital’s “critical capacity plan”, its ED’s staffing levels and an audit of the effectiveness of its waiting room nurses.

Having met with Health NZ the man was “pleased” with the changes it had made, but the decision said he wanted “reassurance” they would follow through with its promises of improvement.

Meanwhile, in another decision released today, the HDC handed out further recommendations to the Wellington Regional Hospital ED, and Health NZ Capital, Coast and Hutt Valley, after the delayed diagnosis of a life-threatening stroke in 2022.

The decision found the patient waited 14 hours before receiving a head scan and was not treated with “reasonable care and skill”.