The importance of critically assessing patients when they present to hospital on multiple occasions with the same
symptoms within a relatively short period of time, and investigating symptoms fully and considering alternative
diagnoses was highlighted in a decision published by Deputy Health and Disability Commissioner Dr Vanessa Caldwell.
In her decision, Dr Caldwell found Whanganui District Health Board (WDHB) in breach of the Code for Health and
Disability Services Consumers’ Rights (the Code) for failing to provide services with reasonable care and skill. She
also referred them to the Director of Proceedings to decide whether any proceedings should be taken.
A Māori man in his 30s presented to Whanganui DHB (WDHB) on five occasions over two months with a recurring infection of
the middle ear (otitis media). During these presentations, clinicians did not undertake adequate investigations to
understand the extent of the disease, and whether the man had developed complications from the otitis media. Sadly, the
man died as a result of a brain abscess, which is a rare but known complication of untreated otitis media.
Dr Caldwell considered the man received inadequate assessment and action in the Emergency Department (ED), including
omitting to perform a CT head scan and not following up abnormal test results adequately.
Dr Caldwell noted DHBs are responsible for the services provided by their staff, and "the clinicians involved in the
man’s care failed to appreciate the significance of his repeated presentations, and take into consideration his history
of poorly resolving symptoms, and the possible presence of complications."
"Given the number of staff involved across multiple presentations, I consider that WDHB must take responsibility at an
organisational level for the widespread failure in its service.
"These failures meant diagnosis of complications arising from the man’s otitis media was delayed, and I therefore find
WDHB in breach of the Code for its failure to provide services to the man with reasonable care and skill.
"It is important that ED staff ensure any suspected drug use is ruled out, so the root cause of any symptoms (which may
be assumed to be due to drug use) can be explored fully," says Dr Caldwell.
Dr Caldwell recommended WDHB and a medical officer provide a written apology to the man’s whānau.
Dr Caldwell made multiple recommendations to WDHB, including review and amendments of its ED on-call policy and
processes for recall of patients, protocols for managing suspected drug use and provide training to staff on
documentation and WDHB’s expectations in relation to management of suspected drug use, and undertake an audit of
positive blood cultures received by the ED to identify whether timely follow-up occurred.
She further recommended the medical officer undertake self-directed learning on bias in healthcare; and reflect on his
care in this case relating to his suspicion of drug use and the appropriate course of action, and his lack of
documentation of discussions and observations.
Dr Caldwell also referred WDHB to the Director of Proceedings and stated that she "had regard to the particular
vulnerabilities of the man and to the public interest in improving healthcare outcomes for Māori".