Dean Carroll, 25, of Coalgate, 60km west of Christchurch, died of blood poisoning a day after being discharged from Christchurch Hospital's emergency department.
An independent report into his death was publicly released on Monday at an emotionally charged press conference attended by his family.
The report cleared the hospital of negligence over Carroll's death, but said it failed Carroll by not offering him the best care.
The report has led to serious soul-searching among the members of the Canterbury District Health Board (CDHB) members who are calling for a thorough review of the hospital procedures.
The failings that the report notes add weight to the family's complaint that Carroll's condition was not taken seriously enough. He waited more than an hour and a half to see a doctor, instead of the 30 minutes which his triage status called for.
Triage is a process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated. It is a system used to ensure the resources are allocated only to those capable of deriving the greatest benefit from it.
The department also had too few senior doctors to provide the expert care and observation which might have detected his rare condition or led them to call for blood tests.
The report blames these failings on overcrowding. It adds that Carroll would have probably received similar care in any major Emergency Department in New Zealand, and that staff at Christchurch Hospital did the best that they could. If so, this is a worrying commentary on what the public can expect when they require emergency hospital care, it is felt.
CDHB members are indeed furious they were not given a high-profile report into the death of Dean Carroll.
It is impossible to say whether better treatment would have saved Carroll's life. But as the Canterbury District Health Board's senior emergency doctor, Professor Mike Ardagh, put it: "Did he have a chance? Did we deny him that chance? We did." Ardagh shares the view that staff were too busy that day, but his frank acknowledgment that Carroll should have been given a better chance contrasts with the report's limp assessment.
The panel behind the report did not interview the nurses involved, relying instead on their written statements. Interviewing them would have given a fuller picture of Carroll's treatment, especially the allegation from his family that at least one nurse was rude to him, it is pointed out.
Several board members labelled the conference a "PR disaster" at Friday's CDHB board meeting, when it was revealed members were not told the report was finished, were not invited to the media conference, and had yet to see the report.
CDHB chief executive Gordon Davies - the board's sole employee - apologised for the oversight, which he said happened largely because he was out of the country when the report arrived. The report arrived late on Friday and was hand-delivered to the Carroll family on Saturday, the earliest possible opportunity.
A press conference was scheduled for Monday, Davies said.
Board member Jo Kane said she was "really angry" about the lack of communication from the CDHB's corporate arm, which meant she found out about the report by reading about it in The Press.
Kane said faith in the board and in the emergency department was "shaky" after the release of the report.
Kane said several GPs had told her the public no longer felt confident visiting the department, putting extra pressure on medics in the community.
Board member Alistair James said he was tired of the board being "hammered" over ongoing emergency department failures.
James called for a special CDHB meeting to discuss the state of the department, and, in particular, to review the recommendations for change made in previous reports.
In 2004, external consultants found Christchurch's emergency department was overcrowded and understaffed and made more than 30 recommendations for action. But fewer than three were implemented.