Inadequate governance and insufficient capacity have been pinpointed as the reasons for delays that resulted in 23 Otago and Southland residents suffering partial sight loss.
An external review of ophthalmology services at the Southern District Health Board was released yesterday, with recommendations including increased capacity of clinical staff, support staff, equipment and physical clinic space.
The review recommended each department, in Dunedin and Invercargill, have a dedicated manager or co-ordinator.
It also noted ''the wider context of significant financial constraints for the SDHB in recent years''. SDHB chief medical officer Dr Nigel Millar yesterday said the organisation ''greatly regrets'' the situation, and apologised to patients and the community for letting them down.
He said the board anticipated the number of overdue patients would be reduced to zero by September.
It emerged last year the patients suffered sight loss in 2015-16 because of ophthalmology delays at the SDHB, and thousands of overdue patients were told they might be affected.
In October, the board wrote to 3239 Dunedin Hospital patients and 1379 Southland Hospital patients who were overdue for an appointment, apologising and telling them the backlog was being cleared.
The review was undertaken by Counties Manukau ophthalmologist Dr James Stewart and Wellington-based health care consultant Kate MacIntyre.
It said in all but one of the 34 cases, the issue was ''entirely that the patient was not seen in a timely manner''.
''We note that since 2015 the DHB has made considerable effort and taken many very worthwhile actions to address the issues raised in this review, but we consider that there is more that needs to be done.''
The review said each ''case'' that was part of the review was a patient who had suffered and worried.
The service lacked capacity, the reviewers believed, because there was no recognition of the big increase in demand for eye clinic appointments to manage chronic eye disease caused by the changes in the last decade.
The increase was primarily because of the advent of Avastin treatment for wet macular degeneration, a previously untreatable condition.
''This occurred in the context of previous under-resourcing, and gaps in ophthalmologist supply in both Invercargill and Dunedin.''
The review looked at 10 cases from Otago, and 24 from Southland.
Reviewers were not convinced all the reported incidents caused harm, but they did not interview patients.
The review concluded 23 cases were ''serious adverse event cases''.
''Many patients suffered marked loss of vision.''
Dr Millar said the review was commissioned as part of a broader service improvement programme begun in 2015.
The number of patients overdue for a follow-up appointment had reduced from 4618 in October 2016 to 3432.
The reviewers recommended new criteria for calculating when a patient was overdue, and by that definition, the number was estimated to be around 2000.
Asked how he would reduce that to zero by September, Dr Millar said the SDHB had extra people working, streamlined systems, and had brought nurses in to perform ''straightforward issues''.
Asked what budget the work had, he said he did not know.
''In the end, we've just got to get the job done.
''We take it very seriously, and greatly regret that the situation could arise, and apologise to the patients who have been harmed, but also to the community for letting them down on the quality of service we've been providing.''
On the review's suggestion of a manager or co-ordinator for both Dunedin and Invercargill, Dr Millar said the SDHB was working out how it was going to do that.
He said it made logical sense to have someone with an overview of each part of the service.
One of the ''important learnings'' from the issue was responding to problems as they arise.
He hoped such an issue would be picked up earlier in future.
''Health is a complex area, this is one of our real challenges, dealing with many lines, 100 lines of service, trying to make sure they're all running smoothly.
''That's what we should be doing.''
Asked if he was comfortable the rest of the SDHB was running well, he said it was ''very inadvisable for someone in my position to feel comfortable''.
''Health will always give us repeated challenges, the real key is to be able to get to them early.''
