Health and Disability Commissioner Morag McDowell today released a report finding South Canterbury District Health Board
(SCDHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for a number of failures in
its care of a woman in 2019.
The woman, aged in her twenties, presented to the Emergency Department (ED) three times with worsening abdominal pain,
vomiting and an increasing CRP level - a marker of infection.
On her third visit to ED, a CT scan found that her small bowel lacked blood supply and was significantly compromised.
Her condition was deemed non-survivable and, sadly, she later died.
The Commissioner considered that the issue in this case was not the failure to diagnose the woman’s condition correctly,
but the failure to investigate the cause of the woman’s symptoms fully, given her increasingly deteriorating clinical
This included the failure to review the woman’s latest blood test results before discharging her; the failure to seek a
General Surgery review of the woman during her second admission; and the failure by multiple clinicians to provide and
document adequate safety-netting advice to the woman when she was discharged.
"I acknowledge the difficulty in making the diagnosis of the woman’s ischaemic bowel, especially in the context of her
young age, high BMI and immunosuppression," said Ms McDowell.
"However, I consider there were missed opportunities at the woman’s first and second presentations for SCDHB to
investigate her condition thoroughly.
"These opportunities may have led to an earlier diagnosis and intervention; however it cannot be said with any certainty
that her ultimate prognosis and outcome would have been any different," she said.
The Commissioner’s recommendations included that SCDHB use an anonymised version of the woman’s case as a basis for
staff training; create guidelines on documentation covering various aspects of a patient’s journey through ED; consider
developing a consensus between ED specialists, physicians and surgeons at SCDHB for management of patients with acute
abdominal pain; and provide a written apology to the woman’s family.
She also recommended the ED consultant complete a clinical notes audit with the Royal New Zealand College of Urgent
The full report on case 19HDC01160 is available on the HDC website.