Doctors worked long hours without taking adequate leave, emergency departments could not meet their targets and in one year 20 patients had surgical equipment left inside their bodies.
This was the NSW health system - stretched sometimes to the point of catastrophe but mostly performing better than it did in previous years, according to the 2016 Auditor-General's annual report.
The Auditor-General singled out excess annual leave, overtime payments and timesheet approvals as shortcomings in the state's financial controls, and ambulance response times, unplanned readmissions and emergency department performance in service delivery.
The report also reported for the first time on "sentinel events", which result in very serious harm or death to patients, counting 47 such incidents in 2014-2015.
"Sentinel events have the potential to seriously undermine public confidence in the healthcare system," the report said.
"A low or decreasing number of sentinel events is desirable."
The number of sentinel events in NSW has been largely stable since 2009, with a peak of 53 such cases in 2013-2014 and a low of 32 in 2010-11.
At the time of the report, sentinel event numbers were not available for 2015-2016.
In 2015, they included 20 patients who required re-operations because instruments or other material were retained after surgery, 15 suicides within an inpatient mental health facility, six maternal deaths associated with pregnancy or birth, three medication errors leading to death and three patients who died or were seriously harmed by gas bubbles entering the blood stream.
Labor health spokesman Walt Secord said the government should reveal the specifics of each case.
"Patients deserve to know that when they undergo a procedure that medical instruments are not left inside of them," Mr Secord said.
"The community has a right to know where these mistakes occurred."
NSW Health Minister Jillian Skinner said sentinel data was routinely reported but the government could not provide more detailed information for privacy reasons.
"The Auditor-General found NSW public hospitals met emergency department triage targets for the third year, which is very pleasing," Mrs Skinner said.
"He found the rate of patients leaving the emergency department within four hours remained stable from 2014/15 to 2015/16 despite significantly increased demand."
The government has set a target for 81 per cent of patients to leave the emergency within four hours, which was not met in 2015-16.
The statewide average was for 74.2 per cent of patients to be treated within four hours and six local health districts fell below 71 per cent, including Sydney, Central Coast, Illawarra Shoalhaven, South Western Sydney, Western Sydney and Nepean Blue Mountains.
"The ministry considers local health districts and specialty networks are not meeting expectations when less than 71 per cent of patients leave emergency departments within four hours," the report said.
"The ministry is working with these local health districts to improve performance in this area and provide more timely access to care in emergency departments."
However, despite an increase in the number of emergency attendances, patients were treated within the clinically recommended timeframes on average for the third consecutive year.
The Auditor-General also raised concerns about the amount of overtime claimed by NSW health employees, with some medical officers earning more in shift penalties than their base salary.
Total overtime increased to $494 million in 2015-16, though overtime as a percentage of wages and salaries was stable at 4.2 per cent.
Four medical officers received more than $430,000 in overtime over the past three years.
