Bay of Plenty residents are right to be concerned about the standard of care being provided by Tauranga Hospital, says Coroner Wallace Bain.

The Coroner released findings into two deaths today that criticise the health care provided by Bay of Plenty District Health Board.

Read about the first death of Ian ‘Curly' Mcleod here.

In a second case Coroner Bain found Marlene Joan Strongman was essentially left to die in Tauranga Hospital on June 23, 2010 after being admitted three days earlier as an acute patient.

She died of a hypoxic brain injury secondary to aspiration pneumonia against a background of a lack of appropriate medical treatment and 'systemic errors” on the part of the Bay of Plenty District Health Board at Tauranga Hospital.

'Citizens in the Bay of Plenty can quite rightly be very concerned at the standard of care being provided,” says the Coroner.

'The Inquest follows on from the Mcleod Inquest. The criticisms of the Bay of Plenty District Health Board are profound and alarming. This District Health Board has failed badly in these two Inquests and needs to do far better.”

Marlene Strongman's care was in several respects in breach of the Code of Health and Disability Consumer Rights, says the coroner. Two individual clinicians were found to be in breach also.

Marlene was referred to Tauranga Hospital by her GP. He was concerned about her vomiting, dehydration an irregular pulse and a groin lump.

A junior registrar provisionally diagnosed her with an abdominal malignancy. Marlene was reviewed by the junior registrar the next day, who then spoke to the GP, who again expressed concerns about the vomiting, but this was not relayed to the consultant.

Marlene had no medical review for 27 hours at the hospital during which time her vomiting continued and her breathing deteriorated significantly. There was a rapid deterioration in her condition and she subsequently died from a severe hypoxic brain injury, which she suffered during a cardiac arrest.

'The Court put to Counsel for the DHB that if there had been appropriate interventions then Mrs Strongman would still be alive,” says the Coroner.

'Counsel accepted that this was a fair assumption and was thanked by the Court for their frank admission and it was noted as being very important. There has been no demure from that position by the District Health Board in their subsequent submissions.”

An ACC hearing concluded there was an unreasonable failure to diagnose Mrs Strongman's condition of incarcerated hernia and bowel obstruction and a failure to make an urgent surgical referral.

The case went before the Coroner's Court against a background of a formal investigation by the Health & Disability Commissioner following a complaint lodged by Mrs Strongman's daughter Jane Taylor.

Jane Taylor gave evidence before the Court, which was forthright and strong in terms of its criticisms of the DHB, says the Coroner.

'What she submitted in evidence was not contradicted at all by the DHB and she was not cross-examined in respect of the stinging criticisms that were contained within it. Her evidence is essentially uncontested,” says the Coroner.

'Her view was that her mother's tragic death was primarily a result of systemic errors on the part of the Bay of Plenty DHB. She was concerned also that the DHB failed to take responsibility in any meaningful way.”

The consultant failed to recognise a hernia with bowel obstruction as a differential diagnosis of her vomiting and groin lump and was in breach of Rights 4(1) of the code of Health & Disability services Consumers' Rights. The code states that every consumer has the right to have services provided with reasonable care and skill.

The junior medical registrar failed to document an accurate history and failed to appropriately relay to his consultant Marlene Strongman's history and the GP concerns.

He was found to be also in breach of the right of every consumer to have services provided that comply with legal, professional, ethical, and other relevant stand