A woman whose husband died suddenly at Palmerston North Hospital says the wait for answers about what happened nearly four years ago is torturous.

Arthur Toms died after suffering a stroke while waiting for urgent dialysis in 2020.

And it appears no one will be held accountable after a Health and Disability Commissioner investigation, leaving his widow, Christine, wondering why she bothered extending her grief while her complaint was dealt with.

The commissioner meanwhile says it was dealing with a huge increase in complaints.

When Arthur Toms died in September 2020 a senior doctor told Christine she should complain to the commissioner, but his advice came with a warning.

"He said, 'The terrible thing is it could take up to two years and during that time you'll be held in a pattern of grief'," Christine says.

"It's taken that much longer and it's untenable."

The commissioner has issued a provisional decision and has now written to Christine to say its final ruling would not be much different.

She says she could not accept that after all this time, and given what happened to her husband, that nobody was held accountable, and all she had was a report she says contained serious contradictions.

She felt like she was nowhere in her search for answers.

"Not in the slightest - just a great deal of grief and a lot of correspondence, a lot of evidence finding, a lot of research, and resulting in nothing, which I think, to be honest, is what the aim was in the first place."

On 16 September, 2020, 75-year-old Arthur Toms received a call from his kidney specialist saying tests showed he had virtually no kidney function and he needed to get to hospital for urgent dialysis.

An ambulance picked him up, but he never returned to his Tokomaru home, dying two days later after a severe stroke.

"He should have gone straight to ICU [the intensive care unit]," Christine says.

"He should have had emergency dialysis, as [his specialist] Dr Curtis Walker had written to ED [the emergency department]. He didn't."

Arthur Toms waits in the Palmerston North Hospital emergency department on 16 September, 2020. Photo: Supplied.

Among the questions Christine says still were not answered was why her husband did not go straight on to dialysis when he arrived at hospital, instead waiting in the emergency ward.

She says before his fatal stroke he suffered an initial stroke in the ambulance which went unnoticed until she arrived at the hospital and saw his impaired state, with his speech slurring.

Christine has footage of her husband sitting in the waiting room trying to get the attention of staff, yet nobody noticed.

Arthur Toms had taken anti-clotting medication, which may have caused his stokes, and Christine wonders why he was shaken awake to get consent for a reversal procedure, rather than staff ask her.

And after he could not be revived, Christine says in the 36 hours before Arthur died they never saw a doctor.

The commissioner's provisional report talks about an educational approach for staff when mild departures from the expected standards were found.

Christine Toms looks over the provisional report into her husband's death. Photo: RNZ / Jimmy Ellingham.

Christine says she found that an insulting response to what she believed was an avoidable death, and what a senior doctor told her was caused by preventable harms.

"An educational approach, I assume, means is that the issues that were found to be wrong would be corrected for the next patient who suffered the same thing.

"I absolutely agree with that and its a wonderful thing, but Arthur should not have been the guinea pig. He should not have had to give his life for their educational approach."

Christine says part of the reason she had kept going with her complaint was because that was what her husband - a folk singer and broadcaster - would have wanted.

'Mild departures from the standard of care'

The provisional decision says it was understandable Christine remained concerned about the circumstances of her husband's "distressing and tragic death".

"My independent expert advisers have identified some mild departures from the standard of care provided to Mr Toms," it says.

"The concerns identified have been acknowledged and accepted by MidCentral District [of Te Whatu Ora] and St John, and changes have been made a result.

"I note that the mild departures from the standard of care did not impact the timeliness of the care Mr Toms received."

The commissioner report writer says an educational approach was the appropriate outcome for concerns about Arthur Toms' documentation, triage criteria on arrival at hospital and testing for blood clotting.

The commissioner told RNZ it could not comment on individual cases.

It apologised to Christine Toms in writing for the length of time it investigation had taken, saying the main reasons were its lack of resources and an unprecedented number of complaints.

It also cited the complexity of this case, as it spanned more than one health provider, and large number of documents on the file.

At a recent select committee hearing Health and Disability Commissioner Morag McDowell says it had experienced a 40 per cent rise in the number of complaints in the past few years.

"This increase has undoubtedly placed us as an organisation under significant pressure and the reality is that, currently, we cannot close as many complaints as we receive.

"This has had flow-on effects. We are growing the number of cases on hand and, regrettably, this means that delays are increasing within our system."

Delays had effects on everyone involved, she says.

"I also want to say though that some complaints will take time and it's appropriate they take time in terms of gathering their information."

In 2022-23, the commissioner received 3353 complaints and closed 3048.

Christine says the resourcing problems needed fixing.

She was speaking with a lawyer about making an ACC claim.

St John says it acknowledged Christine' loss and extended its condolences. It says it had received the provisional report and was reviewing it.

Health New Zealand Te Whatu Ora group director of operations in MidCentral Sarah Fenwick also acknowledged the Christine family's loss, but says it was inappropriate to answer questions about a report that was still provisional.

-RNZ