The Southern District Health Board and agencies involved in patient transportation have come under the coroner's spotlight following the death of a patient from a serious brain injury in 2015.
Warren Peter Bates (45) fell down stairs at his home in Wanaka on February 27, 2015 after drinking with friends, and was taken by ambulance to the Wanaka Medical Centre.
Coroner Anna Tutton, of Christchurch, said he was later taken to Dunstan Hospital, Clyde, where a doctor identified the risk of a head injury in combination with alcohol intoxication, and admitted Mr Bates for observation.
On the afternoon of February 28, another doctor became concerned about Mr Bates' condition and requested he be transferred to Dunedin Hospital for a CT scan of his head and a specialist neurosurgical review.
''Several obstacles were encountered in attempting to arrange the transfer.''
She said no St John road ambulance was available to transfer Mr Bates, and following discussion with a doctor, it was decided his medical condition did not warrant using a rescue helicopter.
''Ambulance transfer using the Dunstan Hospital ambulance was arranged, but there were delays in departing for a number of reasons.
''During the ambulance transfer, Mr Bates became restless, then stiff, with abnormal posturing and subsequently a seizure.
''The ambulance proceeded to Lawrence, the nearest location for assistance, and Dunstan Hospital was contacted and arranged back-up from St John in Lawrence and the rescue helicopter from Dunedin.''
In Lawrence, Mr Bates went into cardio-respiratory arrest and could not be revived.
A postmortem examination found the cause of death was raised intracranial pressure due to an intracranial cyst.
The coroner said the circumstances of Mr Bates' death raised issues relating to the availability of medical facilities and resources at Dunstan Hospital.
''Those issues involve a number of agencies.''
The coroner recommended the SDHB prioritise and accelerate arrangements to enable around-the-clock CT scan services at Dunstan Hospital; and work with all services involved to develop district-wide head injury management guidelines, including clear transfer pathways.
The coroner also recommended the SDHB, ACC, the National Ambulance Sector Office, Central Otago Health Services Ltd, 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.
SDHB chief medical officer Dr Nigel Millar said Mr Bates' death was ''tragic'' and he expressed ''sincerest sympathies'' to the family.
''We accept, and take seriously, the coroner's recommendations made in this case.
''Plans are in place to increase hours in Dunstan Hospital for CT, and a CT scanner is planned for Lakes District Hospital.''
Since Mr Bates' death, the board had introduced new processes for rapid transfer of patients by helicopter and road, which was designed to cover weather events.
''New Zealand out of hospital major trauma destination policy, South Island, has also been developed by the South Island regional major trauma network in conjunction with the national major trauma clinical network and the ambulance sector, for the use of clinical personnel when determining the destination hospital for patients with major trauma in the out-of-hospital setting in the South Island.''
St John medical director Dr Tony Smith said the case had a ''regrettable outcome'' and St John accepted the recommendation of the coroner.
He said St John and the National Ambulance Sector Office agreed the recommendations would help develop a collaborative approach to the transfer of patients within Central Otago.
Dr Smith said St John implemented a major trauma policy in February 2017, whereby patients with a clinical presentation such as Mr Bates' would be transferred directly from Wanaka to Dunedin Hospital, not to Dunstan Hospital.
''St John continues to work collaboratively with Southern District Health Board and ACC to ensure that the patient transfer needs of the Central Otago region are met.''
