A 74-year-old woman died in Dunedin Hospital after her surgery for a broken leg was delayed repeatedly for three days.

A review of the woman’s case found that the delay in her operation was the “root cause” of her death from cardiac issues following a pulmonary embolism and a stroke while in surgery.

Other factors included the fact that her priority status was not changed during the time she was waiting, and possible dehydration as she was kept “nil by mouth”.

The Health and Disability Commissioner (HDC) has found that Health New Zealand Southern breached the woman’s patient rights because of the delay, which saw her bumped down the surgery list several times as other cases were given priority.

The HDC has told Health NZ to apologise in writing to the woman’s family, and report back on changes made at Dunedin Hospital to reduce delays in operating theatre access.

For privacy reasons, the woman was identified only as Mrs A in the HDC report which was released today.

She broke her right femur in 2021 when she was walking her dog in a park and was knocked to the ground by another person’s dog. The decision says she was taken to hospital by ambulance and an operation was originally scheduled for the following morning.

Surgery was eventually performed three days after that, which was four days after her leg was broken.

Mrs A’s daughter, a general practitioner named as Dr B in the report, said she was concerned that her mother waited for more than 90 hours for surgery which should have been performed within 24 hours.

Dr B told the commissioner that a lack of operating theatre resources at Dunedin Hospital continued to be a “chronic problem”.

Dr B said it was her “sincerest hope that [her] mother’s premature passing could serve to highlight, and bring change, to this serious resource allocation issue” through the HDC inquiry.

The HDC report said Mrs A’s operation was supposed to take two hours.

“Over ... three days, Mrs A’s surgery was repeatedly postponed due to limited theatre availability and higher acuity patients being prioritised, some having come from serious motor vehicle accidents,” the report said.

Among other cases, the organ donor retrieval team occupied the acute theatre for four hours on day two.

On day three, four other orthopaedic operations were performed, including one case involving a patient who had been in the hospital since the day before Mrs A was admitted.

However, one of the surgeons involved said that in retrospect, he should have asked a colleague with an elective list to defer this and perform Mrs A’s surgery.

The surgeon also said that no consideration was given to transferring Mrs A to another hospital each time her operation was postponed.

Should she have been transferred to another hospital?

Health NZ told HDC that it did not routinely transfer patients, unless it was for a service it could not provide at the hospital.

The woman’s daughter said she expressed concern about the delay to the orthopaedic team and raised the possibility of transfer to another hospital but was told it was not “logistically viable”.

The HDC report said Mrs A had osteoporosis and had previously had cancer and treatment for an irregular heartbeat, but was otherwise “fit and well” and living independently.

“Limited access to operating theatres at Health NZ Southern has been an ongoing issue for many years,” the report said.

“However, as highlighted in this report, timely treatment for older patients with femoral fractures is particularly important for reducing the risks of morbidity and mortality,” it said.

“In this case, it is clear that the care provided by Health NZ was not adequate, and limited access to operating theatres led to a prolonged delay in surgery, which increased the risk of potential patient harm.”

Health NZ told HDC that it had made a number of changes specifically focused on reducing delayed access to operating theatres.

Among these, assessments are made at the beginning of each day and “the consequence can be that planned care is postponed” if acute cases demanded the theatre time.

Mrs A broke her leg on a weekend. Health NZ Southern said it had recruited and trained enough staff to be able to double the operating theatre capacity at weekends.

Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.