Deputy Health and Disability Commissioner Kevin Allan today released a report finding a district health board in breach
of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a woman with an
ongoing dental infection.
Following an unsuccessful root canal treatment, the woman went to the Capital and Coast District Health Board (CCDHB)
emergency department with facial swelling and worsening pain. Her tooth was extracted and she was admitted to the
emergency department observation unit overnight before being discharged. She was given antibiotics and a follow-up
appointment was arranged.
Over the next five weeks she presented to CCDHB seven times for both scheduled and unscheduled reviews of an ongoing
dental infection. She eventually sought help from her GP to obtain a CT scan and went to another district health board,
where she underwent debridement surgery and was diagnosed with osteomyelitis.
The Deputy Commissioner found that CCDHB did not provide quality and continuity of services to the woman. Osteomyelitis
was not considered as a cause of her ongoing symptoms and, once CCDHB had results to confirm this, treatment was not
initiated in a timely manner.
"Despite repeated presentations with an active infection, no coordinated plan of care was directed by a senior staff
member," said Mr Allan.
"Each presentation appeared to be managed in isolation rather than with overall consideration of the woman’s
non-resolving issues.
"The woman’s experience highlights the importance of critically assessing the reasons behind a consumer’s repeated
presentations to hospital with a non-resolving infection, and providing appropriate care in that context," he said.
The Deputy Commissioner made a number of recommendations to CCDHB to strengthen the Dental Department’s response to
patients who present with non-resolving dental infections, including further training, and improving clinical guidance
and review processes. He also recommended that CCDHB apologise to the woman.
The full report on case 19HDC00256 is available on the HDC website.