Anna Tutton, of Christchurch, has made several recommendations, released today, to the Southern District Health Board and agencies involved in transporting patients following the death of Warren Peter Bates.
Mr Bates (45) fell down stairs at his home in Wanaka on February 27 in 2015 after drinking with friends.
He was taken by ambulance to the Wanaka Medical Centre, then to Dunstan Hospital.
On February 28, Mr Bates died in an ambulance on State Highway 1, in Lawrence, while being transported from Dunstan Hospital to Dunedin Hospital.
Ms Tutton said a post-mortem examination found the cause of death was raised intracranial pressure due to an intracranial cyst.
However, she said the circumstances of the death raised a number of wider issues relating to the availability of medical facilities and resources at Dunstan Hospital.
"Those issues involve a number of agencies.''
Ms Tutton recommended that the Southern DHB prioritise and accelerate arrangements to enable around-the-clock CT services at Dunstan Hospital.
She also recommended the board co-ordinate with all services involved, and develop district-wide head injury management guidelines, including clear transfer pathways.
The coroner has also recommended that the SDHB, ACC, the National Ambulance Sector Office, Central Otago Health Services Limited, St John, the Otago Rescue Helicopter Trust and any other organisations involved in the transportation of patients within the region, work together to ensure the availability of sufficient and appropriate transport options, with contingency plans in place for bad weather.
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One would have thought that, with all the over-paid experienced health professionals in the DHB that there would be no need for the Coroner to make any comment on standard procedural issues in our health-care system. Didn't some-one even ask the ''what if '' during planning/meetings sometime in the last few years??. Use-less...
This is another shameful legacy of the National government . . .