A DHB has been found in breach of Right 4(1) of the Code for failing to ensure that its on-call physician was informed of its patient transfer process, with the Commissioner noting that: "this case illustrates the critical importance of adequate staff orientation in ensuring the provision of appropriate care".

A patient who presented to a rural hospital was diagnosed with a suspected cerebral abscess but was not transferred to the neurological service at the main centre until the next day. The treating physician had recognised that a referral was required, but delayed calling the neurosurgeons until the next morning because he was under the mistaken impression that patients could not be transferred after dark. The Commissioner found that the decision not to consult the neurosurgical service earlier was "suboptimal", denied the patient the opportunity to have specialist neurosurgical advice and consideration of transfer, but did not warrant a breach finding. The Commissioner concluded that the DHB's orientation system was inadequate, that it "must be held responsible for failing to ensure [the physician] was informed about... patient transfer processes". The Commissioner also criticised the standard documentation, noting that: "it is essential to a patient's seamless continuity of care that all clinical reviews and decisions are fully documented". In light of the overall pattern of suboptimal clinical documentation by multiple staff members, the DHB was also found in breach of Right 4(2) for failing to ensure staff met expected documentation standards. 10HDC01344