Health and Disability Commissioner Anthony Hill today released a report finding Bay of Plenty District Health Board
(DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for its failures in its care
of a man in his nineties.
The man presented to the emergency department (ED) of a hospital with severe abdominal pain one afternoon. He was
assessed and treated for gastritis and discharged that evening. The man’s pain worsened overnight. He was taken by
ambulance to the emergency department the following morning in a serious condition. He was diagnosed with having reduced
blood flow to his large intestine (ischaemic bowel) and a blockage to one of the main arteries that supplies blood to
the intestines (superior mesenteric artery thrombus). Sadly nothing could be done to treat the man and he died two days
A number of deficiencies in the man’s care were identified including the delay in seeing a doctor after arriving at the
ED, a five hour delay in taking a complete set of vital signs for the man, the lack of supervision of a junior doctor,
the man not being seen by a senior doctor and the initial misdiagnosis.
While Mr Hill acknowledged that the ED had been busy, he was critical that "the man was not assessed adequately and was
discharged inappropriately, and opportunities were lost to identify and respond to his condition appropriately".
Mr Hill considered that the errors that occurred indicated broader systems and resourcing issues at the DHB and
accordingly found the DHB in breach of the Code.
Mr Hill recommended that the DHB provide a written apology to the man’s family, which it has done. Mr Hill also
recommended that the DHB provide an update on the implementation of an Acute Abdominal Pathway document, conduct an
audit of the past three months of ED wait times, and provide junior ED doctors with clinical documentation training.
The full report for case 18HDC00347 is available on the HDC website.