DHB found in breach of health code
The Bay of Plenty District Health Board has been found in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) following the death of a man in his nineties.
Health and Disability Commissioner Anthony Hill today released a report following an investigation into the incident.
In his report, Anthony says the man presented to the emergency department of a hospital with severe abdominal pain one afternoon.
He was assessed and treated for gastritis and discharged that evening.
"The man’s pain worsened overnight and he was taken by ambulance to the emergency department the following morning in a serious condition.
"He was diagnosed with having reduced blood flow to his large intestine (ischaemic bowel) and a blockage to one of the main arteries that supplies blood to the intestines (superior mesenteric artery thrombus)."
Sadly, nothing could be done to treat the man and he died two days later.
Anthony says a number of deficiencies in the man’s care were identified, including the delay in seeing a doctor after arriving at the ED, a five hour delay in taking a complete set of vital signs for the man, the lack of supervision of a junior doctor, the man not being seen by a senior doctor and the initial misdiagnosis.
While Anthony acknowledges that the ED had been busy, he is critical that "the man was not assessed adequately and was discharged inappropriately, and opportunities were lost to identify and respond to his condition appropriately".
Anthony considers that the errors that occurred indicated broader systems and resourcing issues at the DHB and accordingly found the DHB in breach of the Code.
He recommended that the DHB provide a written apology to the man’s family, which it has done.
Anthony also recommended that the DHB provide an update on the implementation of an Acute Abdominal Pathway document, conduct an audit of the past three months of ED wait times, and provide junior ED doctors with clinical documentation training.
BOPDHB Interim chief executive Simon Everitt says whilst the DHB could not have changed the outcome for the patient in this case, they failed to provide him and his family with the appropriate end-of-life care he and they deserved.
“This was a tragic case for which the BOPDHB has unreservedly apologised to the family, both at the time three years ago, and again more recently.
“In the three years since the case a number of measures have been implemented to help ensure this type of incident cannot happen again,” says Simon.
He says these measures include improved staffing levels in the Emergency Department, with the mix of those staff including an increased number of senior level staff.
This means there is more consultant level supervision for junior doctors.
“All junior ED doctors have also been provided with documentation training at the orientation stage, with an emphasis on improved communication. An admission proforma - which includes guidance on assessments and investigations on elderly patients who present with acute abdominal symptoms – has also been developed.”
Simon says ED waiting times relating to higher acuity patients like the one in this case have been, and are, regularly audited.
The full report for the case is available on the HDC website.https://www.hdc.org.nz/decisions/search-decisions/2020/18hdc00347/