A man in his 20s with severe cardiac issues who died two days after being discharged from Southland Hospital was failed by doctors.
A health and disability commissioner (HDC) decision released this week said the man’s treatment while in Southland Hospital’s emergency department was a "severe departure from accepted practice".
The decision said issues with the man’s care started in 2017 when the patient was applying for a work visa. As part of the process he had to undergo multiple medical examinations with an Immigration New Zealand panel physician.
Seven months later, the patient died on the operating table after initially being discharged by Southland Hospital’s emergency department.
He first went to a GP practice in Invercargill, where an INZ panel physician did his blood tests and a request for a cardiology consultation was made due to issues with a valve replacement he underwent in 2006 after a bout of rheumatic fever.
The patient went to the consultation, and the cardiologist recommended he undergo a valve replacement for valve disease within the next three months. However, he was not eligible for funding for his surgery.
The cardiologist’s report was not sent on until a month later because the cardiologist practice refused to release the report until a payment had been secured from his home country’s government for the surgery.
Two months after his cardiologist appointment, the man was taken to Southland Hospital after experiencing chest pain for seven days.
The man had multiple vital sign abnormalities, was pale and had low blood pressure on arrival, which did not improve when he was discharged later that day. He also had a loss of exercise tolerance, chest pain and shortness of breath that was worsening and at times severe, chest pain radiating to his back, nausea and vomiting.
Emergency department staff sighted the letter regarding the need for a valve replacement. However, no cardiologist was consulted during his first visit.
He was instead discharged and told to follow up with his GP at a later date, and no cardiology referral was made.
The next day, the man was back in the ED with continued and increasing chest pain, and he was immediately sent to the critical care unit with a plan to transfer him to the cardiology department the next morning.
Two days later he was transferred to another hospital, where he deteriorated further while attempts were being made to stabilise his condition prior to valve surgery.
He underwent emergency valvular surgery after suffering a cardiac arrest but died during the surgery.
Independent clinical advice provided to the HDC said anyone presenting to hospital with the symptoms and complications the man had should have been referred from the ED to an inpatient cardiology team.
Instead he was incorrectly placed on a pathway for low-risk patients.
The independent clinical advice said the man was not low risk due to his medical history and the signs he was presenting.
The deputy health and disability commissioner found the initial discharge from the ED was "inappropriate".
"I consider that the overall responsibility to provide an appropriate level of care sat with Health NZ. Accordingly, I find that Health NZ failed to provide [the man] services with reasonable care and skill and breached [the code].
"In my view, [the man] should have received further assessment to consider his symptoms, he should not have been placed on the acute coronary syndrome pathway and he should not have been discharged from Southland Hospital ED."
Doctors involved in the case and Health NZ apologised to the man’s family.
Health NZ has followed up with multiple changes to processes.
