Monday 22 July 2019
Health and Disability Commissioner Anthony Hill today released a report finding Waitematā District Health Board
(Waitematā DHB) in breach of the Code of Health and Disability Services Consumers’ Rights for failings in the care
provided to a woman with Crohn’s disease.
The woman, in her 80s, was admitted to Waitematā DHB for a relapse of Crohn’s disease. While in hospital, she suffered
from a number of episodes of rectal bleeding. Attempts to address her blood loss were complicated by her adverse
reaction to blood transfusions. Two weeks after being admitted, the woman underwent emergency surgery to control her
bleeding. She died a week later.
Mr Hill found that there had been an inadequate response to the woman’s ongoing bleeding and her reactions to blood
transfusions. Junior staff had not appreciated the seriousness of the woman’s condition and had failed to escalate her
condition to more senior staff. Mr Hill was critical that the woman had not been admitted to ICU earlier and of poor
decision-making that led to delayed surgical intervention.
"The failure to involve more senior staff resulted in poor decision-making across multiple specialties, culminating in a
‘failure to rescue’ the woman," Mr Hill said.
Mr Hill also found that there had been a preventable 48-hour delay in carrying out a colonoscopy due to a
miscommunication between teams.
"District health boards have a duty to facilitate continuity of care. This includes ensuring that all staff work
together and communicate effectively."
Mr Hill recommended that Waitematā DHB apologise to the woman’s family, provide HDC with an update on its progress on
recommendations from its own review of this case, and carry out an audit of documentation to ensure that treatment plans
and discussions with other specialties are documented adequately.
The full report for case 16HDC01642 is available on the HDC website.
ENDS