Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
The importance of critically assessing patients when they present to hospital on multiple occasions with the same symptoms within a relatively short period of time, and investigating symptoms fully and considering alternative diagnoses was highlighted in a decision published by Deputy Health and Disability Commissioner Dr Vanessa Caldwell.
In her decision, Dr Caldwell found Whanganui District Health Board (WDHB) in breach of the Code for Health and Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill. She also referred them to the Director of Proceedings to decide whether any proceedings should be taken.
A Māori man in his 30s presented to Whanganui DHB (WDHB) on five occasions over two months with a recurring infection of the middle ear (otitis media). During these presentations, clinicians did not undertake adequate investigations to understand the extent of the disease, and whether the man had developed complications from the otitis media. Sadly, the man died as a result of a brain abscess, which is a rare but known complication of untreated otitis media.
Dr Caldwell considered the man received inadequate assessment and action in the Emergency Department (ED), including omitting to perform a CT head scan and not following up abnormal test results adequately.
Dr Caldwell noted DHBs are responsible for the services provided by their staff, and “the clinicians involved in the man’s care failed to appreciate the significance of his repeated presentations, and take into consideration his history of poorly resolving symptoms, and the possible presence of complications.”
“Given the number of staff involved across multiple presentations, I consider that WDHB must take responsibility at an organisational level for the widespread failure in its service.
“These failures meant diagnosis of complications arising from the man’s otitis media was delayed, and I therefore find WDHB in breach of the Code for its failure to provide services to the man with reasonable care and skill.
“It is important that ED staff ensure any suspected drug use is ruled out, so the root cause of any symptoms (which may be assumed to be due to drug use) can be explored fully,” says Dr Caldwell.
Dr Caldwell recommended WDHB and a medical officer provide a written apology to the man’s whānau.
Dr Caldwell made multiple recommendations to WDHB, including review and amendments of its ED on-call policy and processes for recall of patients, protocols for managing suspected drug use and provide training to staff on documentation and WDHB’s expectations in relation to management of suspected drug use, and undertake an audit of positive blood cultures received by the ED to identify whether timely follow-up occurred.
She further recommended the medical officer undertake self-directed learning on bias in healthcare; and reflect on his care in this case relating to his suspicion of drug use and the appropriate course of action, and his lack of documentation of discussions and observations.
Dr Caldwell also referred WDHB to the Director of Proceedings and stated that she “had regard to the particular vulnerabilities of the man and to the public interest in improving healthcare outcomes for Māori”.
This case relates to a complaint made to HDC in 2019. We aim to investigate complaints as promptly as possible, while ensuring natural justice and the interests of all the parties involved to provide information, and respond to evidence put forward by others is considered.
Names have been removed from the report to protect privacy of the individuals involved in this case.
We anticipate that the Commissioner will name providers found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.
More information for the media and HDC’s naming policy can be found on our website here.
HDC acknowledges the significant pressure the health and disability system is currently under with limited capacity to respond to the demands placed upon it. However, notwithstanding these challenges, people’s rights under the Code continue to apply.
