On 31 October 2023, the Health and Disability Commissioner (HDC) received a complaint from Mr A regarding the standard of care provided to him at Wellington Regional Hospital’s Emergency Department (ED).
Mr A, aged 55 years at the time, presented to Wellington Regional Hospital’s ED at 12.23am on 16 August 2023. He was triaged at 12.44am by an ED nurse. The triage assessment noted that Mr A had experienced three hours of burning, central chest pain, with pain radiating to the back and left shoulder that did not improve after taking Gaviscon.[1] His pain score at the time of triage was 7/10. The assessment also noted his history of gastroesophageal reflux disease[2] and family history of myocardial infarctions (heart attacks). The triage nurse measured Mr A’s vital signs, and the blood pressure was noted to be elevated, while other vital signs were within normal limits. The ED nurse gave Mr A a triage score of 3 (to be seen by an ED doctor within 30 minutes).[3]
Despite being given a triage score of 3, Mr A was not seen by an ED doctor until 5.14am, four and a half hours after the triage assessment. At this point, an electrocardiogram (ECG)[4] was completed, which showed that Mr A was experiencing a heart attack (known as a STEMI [ST-elevation myocardial infarction]). Mr A was urgently referred to the cardiac team and to the Cath Lab, where he had a stent (small tube) inserted to open his cardiac arteries and improve blood flow to the heart.
Health New Zealand | Te Whatu Ora Capital, Coast and Hutt Valley (Health NZ) completed an adverse event report (AER) into Mr A’s care. It identified that the ED nurse considered it likely that the chest pain was non-cardiac in nature given the symptoms of gastritis and pain in the previous days. This resulted in the ED nurse not completing an ECG despite Mr A presenting with symptoms for acute coronary syndrome.[5] However, the AER found that Mr A’s chest pain was likely to have been of a cardiac nature.
Health NZ’s AER found that Mr A was given an incorrect triage score and that he should have been given a triage score of 2 (to be seen within 10 minutes). Health NZ said that a correct triage score would have led to a timelier assessment and intervention for Mr A.
Health NZ said that, at the time of Mr A’s presentation, the ED was at 200% occupancy and had 20 patients who needed to be seen within four hours. In addition, there was a shortfall of 10 nurses for the shift.
Mr A and Health NZ were provided with a copy of the provisional report for comment. They had no comments to make.
Opinion – Health NZ – Breach
In my opinion, Health NZ failed to provide Mr A with an appropriate standard of care. Although it is important to guard against hindsight bias, I am satisfied that, at the time of his presentation to the ED, Mr A was presenting with symptoms of a cardiac nature that warranted undertaking an ECG as part of his initial assessment. His symptoms and history should have raised immediate suspicion of acute coronary syndrome given his age (55 years), gender, ethnicity (Māori), and family history. The failure to recognise this led to him being assigned an incorrect triage score of 3 instead of 2 and a wait to be seen by a doctor that was inappropriate and well outside the expected timeframes even for the incorrect triage score. I acknowledge the strain on nursing resource; however, in my view, by not recognising that Mr A’s symptoms were of a cardiac nature, not applying the correct triage score, and delaying the completion of a medical assessment to well outside timeframes expected by the ATS, Health NZ breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights by not providing services to Mr A with reasonable care and skill.
Health NZ offered its sincere apologies to Mr A. I also acknowledge Health NZ’s remedial efforts in:
providing triage nurses with further education on recognising cardiac symptoms;
planning to develop a hospital-wide escalation process for when the ED is at critical capacity;
increasing its budget to accommodate an additional 63.71 full-time equivalent (FTE) staff;[6]
introducing a waiting room nurse in 2024 to support the undertaking of clinical investigations following triage; and
requiring that all ED nurses attend an external triage course with the College of Emergency Nurses NZ.
In addition, this year, the Government announced further investment to upgrade Wellington Hospital’s ED.
Mr A has met with Health NZ to discuss the AER and is pleased with the changes that Health NZ has made; however, he would like assurance that these recommendations are being adhered to. Accordingly, I recommend that Health New Zealand | Te Whatu Ora Capital, Coast and Hutt Valley:
audit the last 30 cardiac presentations in the ED to determine whether the triage score was appropriate. A summary of the audit findings and corrective actions to be implemented is to be provided to HDC within three months of the date of this report;
provide an update on the development of the hospital-wide escalation process within three months of the date of this report;
provide a further update on its recruitment within the ED, including whether the current staffing levels are acceptable, within six months of the date of this report;
report on the effectiveness of the waiting room nurse role, including any changes to be made, within three months of the date of this report;
undertake a further audit of the ED’s compliance against the timeframes listed in the ATS. A summary of the audit findings and corrective actions to be implemented is to be provided to HDC within 12 months of the date of this report.
A copy of this report with details identifying the parties removed, except Health New Zealand | Te Whatu Ora Capital, Coast and Hutt Valley and Wellington Regional Hospital, will be sent to the Ministry of Health, the Australasian College for Emergency Medicine, and the College of Emergency Nurses NZ and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.
Morag McDowell
Health and Disability Commissioner
[1] An antacid used to relieve heart burn.
[2] A chronic condition where stomach acid flows back into the oesophagus, causing symptoms such as heartburn and regurgitation.
[3] As per the Australasian Triage Scale (ATS; ACEM - Triage). A triage score is used to establish the maximum waiting time for medical assessment and treatment of a patient in the ED.
[4] A test that records electrical signals in the heart.
[5] A medical emergency characterised by sudden reduced blood flow to the heart.
[6] As of August 2025, 43 FTE have been recruited into the ED.