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A man with recurring, painful abscesses suffered unacceptable delays and poor communication while trying to get treated at Southland Hospital.
An investigation by the Health and Disability Commission found Te Whatu Ora Southern failed to provide appropriate care and communication.
The man, who was in his 20s at the time, sought treatment between November 2019 and March 2021 for repeated anal abscesses, but suffered multiple referral delays and communication failures.
His abscesses burst on at least two occasions, including once while he was waiting in the ward for treatment.
The man told the commission he rang for assistance and a nurse said they did not want to clean the fluid until the surgeon could review him.
"I was left sitting in the abscess drainage for eight hours. This was an extremely uncomfortable and humiliating experience and to make matters worse, there were three other patients in [the] room who could hear, see and knew the state that I was in," the man said.
He attended a surgical follow up appointment on 18 September 2020, where it was determined he should be reviewed by the colorectal team.
While a referral letter was written and a clinic letter was dictated on the same day, it wasn't typed or approved for sending until four weeks after the appointment.
On other occasions, the man was referred to the wrong unit, his referral was not received by the referral centre, or it was closed prematurely, with the patient resorting to personally following up with a colorectal nurse after hearing nothing about his appointment ,despite his GP advocating on his behalf.
In the end, he received a referral from Te Whatu Ora Southern and underwent surgery privately.
Deputy commissioner Deborah James was critical of the way Te Whatu Ora managed communication about the man's condition and the lack of courtesy and respect shown to him.
James said he had a painful condition that affected his quality of life and employment, including running out of sick leave and the subsequent financial implications.
"Overall, Mr A experienced multiple unacceptable delays in the management of his referrals and confusion about the appropriate service to provide his care. This resulted in Mr A not receiving timely consultations and treatment, despite having been prioritised as urgent," she said.
Te Whatu Ora's target timeframes are two weeks for urgent referrals, six weeks for semi-urgent and 12 weeks for routine.
"I am critical that there was not a process to record queries and ensure that an appropriate person responded [to] and supported Mr A. This was poor care that contributed to Mr A's ongoing discomfort. I am [also] critical of the lack of courtesy shown to enable timely information and access to treatment."
James recommended Te Whatu Ora formally apologise to the man and improve its referrals and patient management.
Te Whatu Ora had reviewed its colorectal services and made changes to reduce paper referrals, develop a quick guide for consistent triaging, and improve patient management and bookings, she said.
"Te Whatu Ora stated that the issues raised by the delay in sending Mr A's dictated referral letter have now been resolved and systems have been put in place to ensure that this does not happen again. Te Whatu Ora said that each clinic letter and referral is now typed in a timely manner."