Tutton said a post-mortem examination found the cause of death was raised intracranial pressure due to an intracranial cyst.
However, she said the circumstances of the death raised a number of wider issues relating to the availability of medical facilities and resources at Dunstan Hospital.
"Those issues involve a number of agencies."
Dr Visser, of Dunstan Hospital, believed that if better resourced patient transfer services and improved communication with specialist services at Dunedin Hospital were available, then those factors may also have impacted on the outcome of Bates' death.
Dr Wickremesekera, a neurosurgeon of the Capital and Coast District Health Board, also reported that the delay in transfer of Bates' to Dunedin Hospital and the delay in getting an ambulance or helicopter contributed to the outcome.
Three years after Bates' death, CT scanning is still unavailable at Dunstan Hospital after 8pm on weekdays and during the weekend.
Despite a Southern District Health Board review concluding that the CT service at Dunstan Hospital should be available 24 hours, Dr Millar of the SDHB said funds would need to be prioritised in order to achieve this.
"SDHB cannot guarantee the availability of all possible services in all places without considering the impact on the delivery of health services as a whole," he said within the inquiry.
"Put simply, money spent on enabling 24/6 CT services at Dunstan Hospital will take money away from a service somewhere else. At this time we do not consider the implementation of a 24/7 CT service in Dunstan as warranted."
Tutton recommended that the Southern DHB prioritise and accelerate arrangements to enable around-the-clock CT services at Dunstan Hospital.
She also recommended the board co-ordinate with all services involved, and develop district-wide head injury management guidelines, including clear transfer pathways.
"Particularly in light of its setting in an area of rapid population growth and tourist activities carrying a high risk of head injury," she said.
"It is my view that progress to provide 24 hour CT services must be accelerated."
The coroner also recommended that SDHB co-ordinate the development of district-wide head injury management guidelines, including clear transfer pathways.
The coroner has also recommended that the SDHB, ACC, the National Ambulance Sector Office, Central Otago Health Services Limited, St John, the Otago Rescue Helicopter Trust and any other organisations involved in the transportation of patients within the region, work together to ensure the availability of sufficient and appropriate transport options, with contingency plans in place for bad weather.
- Additional reporting Meghan Lawrence
