In her decision released yesterday, Health and Disability Commissioner Morag McDowell said Health New Zealand Te Whatu Ora (HNZ) had not provided adequate care and had breached the Code of Health and Disability Services Consumers’ Rights in relation to the incident.
In 2021, a 74-year-old woman referred to as Mrs A waited more than 90 hours for an operation to repair her femur as restricted theatre hours and high demand for priority cases meant her operation was delayed.
However, during surgery, she suffered a pulmonary embolism and a stroke. She continued to deteriorate after the operation and died three days later.
"Limited access to operating theatres led to a prolonged delay in surgery, which increased the risk of potential patient harm," Ms McDowell said.
Mrs A was knocked to the ground while walking her dog in a park and taken to Dunedin Hospital by ambulance, in severe pain and unable to stand.
She had previously been diagnosed with osteoporosis, but was otherwise "fit and well" and living independently.
She had a fractured femur and needed surgery, which was booked for the following morning.
However, a preoperative CT scan was not done in time and the operating theatres were in use for the rest of the day.
While the theatres were available overnight and during the weekend that followed, they were limited to operations on patients with a higher priority level.
Mrs A’s daughter, a GP referred to as Dr B, was concerned about the length of time her mother had waited for surgery, which should have been performed within 24 hours.
"She believes that ‘[her] mother’s demise was a direct consequence of a lack of acute surgical theatre availability’," Ms McDowell said.
Dr B understood there were a higher-than-usual amount of high need cases prioritised ahead of her mother, but said the hospital needed a contingency plan, such as a hospital transfer, instead of delaying surgery.
"Lack of theatre resources at Dunedin Hospital continues to be a ‘chronic problem’ and it is her ‘sincerest hope that [her] mother’s premature passing could serve to highlight, and bring change, to this serious resource allocation issue through the assistance of the Health and Disability Commissioner’," Ms McDowell said.
HNZ’s own investigation found surgery delays were the "root cause" of Mrs A’s death and had recommended changes such as reviewing guidelines for patent priority status and investigating a daily review of inpatients’ physiological status.
It was "well aware" of limited space in theatres and was working to increase its resources.
Ms McDowell made series of recommendations to HNZ Southern including an option to transfer patients after delays and using an anonymised version of the case for teaching purposes.
HNZ have apologised to the patient’s family.
