Commissioner Deborah James found in a decision released today the man’s rights under the Code of Health and Disability Services Consumers’ Rights were breached by Health New Zealand/Te Whatu Ora Southern and a registrar who did not provide services with reasonable care and skill.
Ms James said the man had an unwitnessed fall at his care home and was taken to Southland Hospital emergency department.
A yellow envelope containing important patient information was misplaced which meant that hospital staff who were treating the man were not aware he was on anticoagulants.
It was six hours after his arrival before the man had his initial observations taken by a registered nurse and he was first seen by the registrar three hours after that initial assessment.
She said the registrar noted it was usual practice for her to review the information in the yellow envelope, however there was not one available at the time.
The registrar then did not order a CT scan because she was not aware he was on anticoagulants and he was kept under observation and discharged back to the care home the next day.
The man then became increasingly ill and was taken back to Southland Hospital where a CT scan showed he had experienced an intracranial haemorrhage - he later died.
Ms James said Health NZ breached the Code by not providing services with reasonable care and skill during a series of mistakes.
"Health NZ did not have a clear or well understood process in place for ambulance staff to hand over the yellow envelope when there were no available beds in ED, resulting in the man’s yellow envelope being misplaced."
She added that the man was not assessed for initial observations until around six hours after his arrival and that several clinicians had failed to identify he was on warfarin [anticoagulant].
These factors combined meant Health NZ did not provide the appropriate standard of care, she said.
"Due to the man’s age, fragility and because he had suffered a head injury, a CT scan should have been completed, regardless of whether or not he was on anticoagulants."
Health NZ told the commissioner that since then it has increased the number of nurses during the night shift and they also made sure there was always a medical imaging technologist on site to take scans.
Ms James recommended both parties to formally apologise to the man’s family.
She also told Health NZ standardise its process for yellow envelopes to cover when there are no beds available.
