Health and Disability Commissioner Anthony Hill today released a report finding Capital and Coast DHB in breach of the
Code of Health and Disability Services Consumers’ Rights (the Code) for a pattern of poor care in the assessment of a
woman who was later found to have a brain tumour. Mr Hill also found a doctor at the DHB in breach of the Code for
failures relating to his assessment and follow up advice.
The woman went to the DHB’s emergency department (ED) having collapsed multiple times that day and with pain in her neck
and vomiting. She was not offered a CT scan or referred for an urgent neurology review, and was discharged with advice
to see her GP if she started to feel worse.
She continued to experience these symptoms and following a seizure and loss of consciousness went again to the ED about
two months later. No neurological assessment was carried out in ED before the woman was referred to the general medicine
team. This referral was initially declined before a second referral was accepted. The woman discharged herself from the
ED and was later found to have a brain tumour.
Mr Hill considered that aspects of the care across both presentations were suboptimal. He was critical that the woman
was not offered an adequate neurological review at either presentation and that the general medicine team declined a
referral without assessing her. Mr Hill was also concerned by a lack of documentation which he said could have affected
the quality and continuity of services.
Mr Hill was critical of a general medicine consultant for not arranging a CT scan, or providing the woman with more
formal follow-up or advice when she was first discharged.
"A busy environment does not remove the obligation to provide good services, and does not remove the accountability for
ensuring that appropriate steps are taken," Mr Hill said.
Mr Hill recommended that both the consultant and the DHB apologise to the woman. He also recommended that the DHB
consider a number of changes relating to the overview by consultants of junior doctors’ cases, and consultant
involvement in cases where patients re-present to ED or where they wish to leave hospital against medical advice; and
changes relating to documentation and criteria for urgent CT head scans, including ongoing education in relation to
The full report for case 17HDC00975 is available on the HDC website