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. '"/>




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