Waitemata District Health Board has been told it did not do enough to prevent overcrowding at North Shore Hospital in 2007, when patients were left on trolleys in corridors.
Health and Disability Commissioner Ron Paterson, who began his investigation more than a year ago, says the hospital provided substandard care to a group of elderly patients in 2007. Four of the five patients died, though the report says there is no evidence that was not due to lapses in their care.
Mr Paterson says the hospital's emergency care centre and two wards were overwhelmed in the winter of 2007 because the board did not act with sufficient urgency.
What emerges, the commissioner says, is a picture of an overcrowded hospital, staff who were stretched and stressed, and patients and families who were left in the dark about patients' condition, prognosis and plan of care.
The partner of one of the elderly patients says the SPCA's dog kennels are cleaner and better run.
Arie Grootegoed says his partner Lois spent 36 hours in the emergency department with gastric bleeding before being sent home with a broken hip.
Mr Grootegoed says even though his partner was in great pain she could not wait to leave the hospital and pleaded with him to take her home.
However, he says she had to return soon after for surgery on her hip and died there eight days later.
Situation improved - board
The board says it has apologised to the patients and families who were affected.
Board chief executive Dave Davies says action has already been taken, including adding 62 beds in 2007 and an eight-bed high-dependency unit. By next year, 27 more beds will be added.
The board says a $48 million extension to the hospital will reform acute and emergency care completely in 2011.
The former chief executive of the district health board, Dwayne Crombie, describes the report as unfair and a "beat-up".
Dr Crombie says the report itself makes clear none of the deaths that occurred was due to any medical misadventure caused by the health board.
He says district health boards are the whipping boy for funding problems,and while Treasury, the Health Ministry and politicians are aware of the shortage of beds in the Auckland region, they do not want to know about it unless it can be dealt with in annual funding grants.
Dr Crombie says the health board spent nearly $180 million on developments at Waitakere and North Shore Hospitals between 2000 and 2008.
Details of report
Mr Paterson looked into the care five elderly patients received at the hospital's emergency department in 2007. Four of the patients died, though he says there is no evidence that treatment injuries or lapses in care caused their death.
In one case, a patient in her 80s, who was supposed to spend 18 hours in the emergency centre, was there for double that time. After the woman was discharged it was discovered she had a fractured right hip and was re-admitted for surgery, but died eight days later.
An 81-year-old woman was admitted after having had a severe stroke and a heart attack. She was transferred to ward 11 and died there. Her son said he was "disgusted" at her care and felt "helpless and confused as to what to do".
The commissioner says the serious problems associated with the patients' care amounted to failures by the health board management, not nurses or other staff.
North Shore Hospital Emergency Care Centre and medical wards 10 and 11 were ill-equipped to cater for the flood of patients in the winter of 2007, he says, and the hospital's acute care services were overwhelmed.
Mr Patterson says it was not until the overload of winter 2007 was "bearing down on it" that the board took action to approve beds and future development.
Associate Health Minister Jonathan Coleman backs the finding of the report, saying it points up that despite fiscal pressures there are things the board could have done to alleviate the problems.
Association of Salaried Medical Specialists executive director Ian Powell says that with the exception of Dr Crombie, senior managers did not act on the concerns of doctors and nurses.