The emergency department at Middlemore Hospital was "abnormally busy" when a patient, who later died, left of her own accord, according to a review led by Chief Medical Officer Dr Andrew Connolly.
Connolly says the patient didn't register at the front desk on June 16 and wasn't triaged for medical assessment.
"The patient was not declined care or sent home but left the department after becoming aware of long waiting times for a non-urgent consultation with a doctor," he said in a review released to 1News on Wednesday.
The patient then had a "catastrophic" medical event at home a few hours later and returned to Middlemore at 5.30am.
The patient did not respond to the immediate medical treatment and died the following day.
READ MORE: Call for greater transparency over Middlemore patient death
The review confirmed that at the time of the patient arriving at 1am the ED was "abnormally busy" with nearly 200 patients.
Staffing was at normal levels and there was a nursing staff shortfall of three compared to normal roster numbers of 32.
READ MORE: Patient dies after leaving Middlemore ED due to wait time
Connolly said there were at least 46 patients in the waiting room at 1am and a message was given to people in the waiting room that the time for a consultation for non-urgent cases would be hours.
"It is not possible to determine if the outcome for this patient would have been different if they had of remained in the emergency department, however we are seeking an external expert review of the incident," he said.
The review also listed some improvements to be made by Middlemore Hospital.
It said there should be more communication about waiting times and the possible alternatives, including going home.
"This should be explicitly directed to patients who have been via triage, had appropriate recordings taken, and been told their Triage category means their waiting time is likely to be excessive.
"Messaging about waiting times also needs to be understood by all those affected," the review states.
"This includes in language understood by each patient, otherwise there is increased clinical risk of a patient leaving when the clinical intention is they should remain.
"The overarching improvement necessary is to eliminate excessive demand over and above departmental capacity."
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