The standard of care given to a man by a consultant physician at Whangarei Hospital was "significantly below the standard expected", with the man later dying.
The Health and Disability Commissioner has released a damning report into the death of a 69-year-old man who was admitted to Whangarei Hospital's emergency department (ED) in mid-2009.
Commissioner Anthony Hill said the case was about a series of systemic and individual failures within Northland District Health Board (NDHB) that led to the unacceptable delay in a man's clinical management and treatment. NDHB said it could not comment on the case at this stage as Chief Medical Officer Mike Roberts was away until today.
Mr Hill said the man was admitted on a Saturday after experiencing blood-tinged vomiting and was assessed as having an upper gastrointestinal (GI) bleed. He was reviewed by a locum consultant physician the next day, who confirmed the man was suffering an upper GI bleed, and referred him for a gastroscopy.
The consultant reviewed the man again on Monday, but despite his clinical notes recording ongoing vomiting, the consultant continued with the diagnosis of GI bleeding and the plan for gastroscopy. The man began to deteriorate and the gastroscopy was deferred. The following day the man vomited more blood, collapsed and died.
As the death was not referred to the coroner the exact cause of death has not been established.
Mr Hill said the man's ongoing vomiting and severe back pain should have alerted the consultant and the medical team to consider alternative diagnoses and other clinical investigations.
The consultant's failure to do so breached Right 4(1) of the Code of Health and Disability Services Consumers' Rights (the Code). He said NDHB did not have clear guidelines or clinical criteria for gastroscopy referral and the consultant's care was below the standard expected of a consultant physician.
"Further, it did not have a protocol in place to sufficiently assist and guide its staff to review and manage the risk to an acute patient thought to have an upper GI bleed, whose management may require medical and surgical team co-operation," the commissioner said.