Code Red: Hundreds of critical hospital overload incidents

Saturday, 14 June 2025

A code red is a “critical” gap between patient demand and staff ability to cope, which can cause Emergency Department snarl-ups and mean patients can’t get pain relief on time.

Overstretched central region hospitals went into code red hundreds of times in 2024, with pressure hitting critical levels.

Nurses and doctors say that can mean patients suffering in pain while waiting for medication, sleeping on trolleys in the emergency department, or waiting too long for treatment or admission, increasing the risk of death.

Data obtained under the Official Information Act shows Hawke’s Bay Hospital was overstretched at some point on almost half the days of 2024, recording 162 days with a “critical” mismatch between patient demand and available staff.

Hawke’s Bay was one of three “hotspots” identified in a 2024 document, which highlighted pressure on beds and problems moving patients through the hospital, impacting on care quality and safety.

Hutt Hospital had 80 shifts that went into code red, and Wairarapa had 25 code reds overnight - amounting to one in every 14 night shifts.

Wellington and Kenepuru hospitals reported no code reds.

Code red is the fourth step in a traffic light system that matches staff availability and patient demand. Red is defined as a “critical care capacity deficit”.

Code red is defined as a 'critical care capacity deficit'.

Nurses Organisation delegate and Hutt Hospital duty nurse manager Nathan Clark said that could stall hospital admissions, or prevent surgery patients getting back from theatre. And for patients on an overstretched ward, staff could do only the bare minimum needed to keep people safe.

“There could be delays in medication, antibiotics, pain relief … You ring the bell and you’re waiting and waiting and there’s just not the staff there. Someone’s in pain, someone’s in distress, someone needs help and support.

“It gives people a really bad, negative response to being in hospital. It’s a challenging time, to deal with the best people on their worst days of their life in hospital.”

While code reds could be short, such as an all-hands response to a patient crisis in one ward, they could also last an entire shift. Wairarapa’s code reds lasted up to 7½ hours.

Association of Salaried Medical Specialists delegate and Wairarapa emergency specialist Norman Gray said a hospital code red could prevent patients being moved from ED into a hospital bed, meaning cubicles then could not be cleared for those waiting to be seen.

“When we get to the worst situations … the whole system’s gridlocked. There’s no magic wand to wave.

Wairarapa emergency specialist Norman Gray said the current hospital pressures were the worst he’d seen in 11 years in New Zealand. (File photo)

“That might mean lying on a trolley for hours when you should be in a hospital bed, or waiting with your screaming kids.”

And if ED patients waited longer than the six-hour target to be discharged or admitted, that increased the risk of death in the following week by 10%, Gray said.

“So that's the ultimate price we pay ‒ increased mortality.”

Gray argued more staff and beds were needed to relieve the pressure, which was the worst he’d seen in his 11 years in New Zealand.

An eight-patient transit hub was opened at Hutt Hospital in 2023, and code red numbers dropped from 2023 to 2024. But Clark said bed numbers had not kept pace with the growing ‒ and ageing ‒ population.

A December 2023 Health NZ national report noted “we cannot build hospital capacity fast enough to meet the forecast demand”. Without a radical change in the way care was delivered, an “unaffordable” extra 4900 hospital beds would be needed by 2043, and 90% of those would be filled by people older than 65.

Hospital overload can also be caused by patients waiting for a care home bed clogging up the system, Clark said.

“It becomes very, very tricky when you have someone of high needs and limited aged residential beds … We can’t get people out of hospital, we can’t get them into hospital.”

Care bed vacancies in Lower Hutt are 'very tight'.

Eldernet provides daily updates on rest home bed availability. Director Esther Perriam said there were currently plenty of beds in Hawke’s Bay, but Lower Hutt was “incredibly tight”, with fewer than five free beds at each level of care.

Even areas with apparently ample supply could be deceptive, as some rooms required a premium charge or even a capital investment to buy in, Perriam said.

“If you can pay more, you have more options … There probably is a bed, but it might not be exactly where they want it to be, or at a cost they can afford.“

Age Concern chief executive Karen Billings-Jensen said accepting you could not return home was tough, and doing that from a hospital bed ‒ or busy, crowded transition unit ‒doubly so. The shift also came with legal and financial complications.

“There's a whole lot of complexities … While there might be some vacancies, it may not be in the same community, and I think everyone really has the right to age in the community that they know, love and live in.”

Clark said the best way to free up hospitals was to improve access to family doctors, so people got help before they got too sick.

Hawke’s Bay Hospital had 162 days where the hospital was in red at some point.

“The pressures are getting worse … They talk about the hospital being the ambulance at the bottom of the cliff, but we need to put a fence around the top of the cliff to stop people falling over, and that is good access to timely primary health care.”

And while the Government has promised $164 million over four years to expand urgent and after-hours services, they’re still unaffordable for many, Clark said. Lower Hutt After Hours Medical Centre charges $80 for adults even with a Community Services Card, and shuts at 10pm.

Asked if so many instances of “critical care capacity deficit” were acceptable, Health NZ said hospital demand could change rapidly and the system allowed hospitals to redeploy staff between areas.

“The colour codes are not a sign of failure, they’re a tool that supports hospitals to respond rapidly and effectively, maintaining the highest levels of care and safety for patients and staff.”

However, Health NZ acknowledged that hospitals were experiencing growing demand, with record ED presentations and acute hospital admissions and longer hospital stays.

To help achieve the Government’s rebooted six-hour ED treatment target, Health NZ was working to improve patient flow across the ED, hospital wards and community care providers.

“This whole-of-system approach ensures patients receive the right care in the right place at the right time.”