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Source: MIL-OSI Submissions

Source: Health and Disability Commissioner

Health and Disability Commissioner Anthony Hill today released a report finding a District Health Board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill to a man after he presented at an Emergency Department (ED).
The man presented to the ED after he fell over, hit his head, and lost consciousness. He was also suffering from chest pain. The man was discharged and later admitted to another ED with a triage code of 3, meaning that it was recommended he be medically reviewed within 30 minutes. The discharge summary from his first admission that arrived with the man was in draft form, and did not mention him having had chest pain or a rise in troponin T (which can be indicative of heart injury).
There were communication failures at the DHB as to the man’s symptoms, which resulted in the ED Cardiology registrar prioritising other patients who appeared to have more urgent presenting complaints first.
The man became unresponsive and CPR was commenced. Unfortunately the man could not be resuscitated and passed away before he could be seen by the Cardiology service.
While it is not possible to say whether earlier medical assessment would have altered the outcome for the man, Mr Hill considered the failure to provide timely medical assessment in the ED fell outside of the standard of care that should have been met. He noted that the man’s wait time was well outside of the recommended triage time, and that systemic issues at the DHB contributed to the long delay in the man being seen by medical staff.
Mr Hill recommended that the DHB consider implementing a formalised process where an ED clinician reviews the patient’s clinical picture if there is to be a significant delay in the inpatient service review of the patient.
Mr Hill also recommended that the DHB provide a report with feedback on the efficacy of changes to its Cardiology service rostering, and provide a written apology to the man’s partner.
The full report on case 18HDC01563 is available on the HDC website.