Commissioner Deborah James found in a decision released yesterday that the man’s rights under the Code of Health and Disability Services Consumers’ Rights were breached by Te Whatu Ora Health New Zealand Southern (HNZ) and a registrar who did not provide services with reasonable care and skill.
The report stated the man, in his 80s, had an unwitnessed fall in 2020 at his care home and was taken to Southland Hospital emergency department (ED) along with a yellow envelope which contained vital notes, including that he was taking blood-thinning medicine at the time.
Ambulance staff said they handed it to the "person working behind the glass screen in the ED waiting room", but the staff who were working that night had no recollection of it and the yellow envelope was lost.
The man — called Mr A — arrived at Southland Hospital at 10pm and was placed in a wheelchair in the waiting room and allocated a triage category of four, which meant the maximum clinically appropriate triage time was 60 minutes.
However, it took around six hours for a registered nurse to undertake an official assessment. It included an early warning score of 0 or "not of concern", despite the patient being unable to say where he was, or what city he was in.
It then took more three hours until a doctor, named Dr C by the court, went to see him.
Her notes stated he had been waiting a long time to be seen, he had a head wound of 10cm and that "he smelt strongly of urine and had a full catheter bag".
"Dr C also noted Mr A was not understanding assessment instructions and that he was ‘slow and shaky’."
She told the commissioner she was unaware that Mr A was taking a blood-thinning medicine, and because of that she did not order a head CT scan.
"Dr C said that had she been aware of Mr A’s warfarin therapy, her usual practice would be to perform a CT of his brain prior to discharge."
His head was sutured, but due to the limited availability of beds, he was kept in a wheelchair — he was discharged at 10am.
The day after the discharge, the care home referred him to his GP because he was unwell with increased confusion and shakes — his GP said he had not received a discharge summary from Southland Hospital.
After a couple of days, the care home staff noticed a further decline in the man’s state and he was again transferred to Southland Hospital, where an urgent head CT was performed.
It showed he suffered an intracranial haemorrhage and consequently he died.
Ms James said that due to the man’s age, fragility and the fact he had suffered a head injury, a CT scan should have been completed, regardless of whether or not he was on anticoagulants. She found the registrar had breached the code, by not providing reasonable care and skill in the management of the man’s symptoms by not ensuring a CT was completed or identifying that he was on anticoagulants.
Ms James has recommended that both parties formally apologise to the man’s family and recommended HNZ carry out a series of changes, including standardising its process for yellow envelopes to cover when there are no beds available. Ms James said that education for ED staff on where to source medication information in the absence of it being supplied, should be carried out.
HNZ southern chief medical officer David Gow said to the Otago Daily Times yesterday HNZ accepted the findings and recommendations and its aim was to always provide excellent healthcare to patients.
"We deeply regret that in this case we did not meet those high standards.
"We have apologised to the patient’s family for the failings identified in the report that led to this tragic outcome."
He also stated HNZ had taken significant steps to implement the recommendations, which included ongoing training for staff "to minimise the risk of an incident like this occurring again".
