A patient who was self-administering morphine repeatedly to relieve his pain while a serious complication was missed should have been checked more thoroughly to find the source of his discomfort, the Health and Disability Commissioner says.
In a report released yesterday, Anthony Hill found the Southern District Health Board breached the patient rights' code twice, by failing to provide services with reasonable care and skill, and by failing to provide services that were consistent with the patient's needs.
''I consider that SDHB is responsible for this failure by multiple staff members to investigate the cause of Mr A's pain adequately, which in turn led to a delay in diagnosing Mr A with compartment syndrome.''
Compartment syndrome happens when muscular bleeding or swelling restricts blood flow.
Without decompression it can cause muscle death.
The 29-year-old went to hospital on December 31, 2013, with a broken leg, and received surgery the next day.
The procedure, in which a rod was inserted, went as planned, and he was hooked up to a pump to self-administer morphine.
He also received regular painkillers orally.
The morphine pump dispensed 1 milligram (mg) at a time, with a 5-minute lockout.
On January 2, he used the pump 66 times, and received 38mg of morphine.
The next day, experiencing increased pain, he used it 115 times, receiving 64mg of morphine.
At 1.45am on January 4 a junior doctor examined him but discounted the possibility of compartment syndrome, as he could still move his toes.
On January 4, he used the pump 316 times, receiving 102mg of morphine.
A few hours later, when he was in ''considerable distress'', the diagnosis was made.
He was rushed into surgery to relieve the pressure.
The patient's mother told Mr Hill her son's ''escalating uncontrollable pain'' should have meant an earlier diagnosis.
''Although it was documented in the notes that my son was comfortable I would like to suggest to you that in fact he was drowsy and unable to function due to the amount of analgesia he was receiving.''
The patient needed numerous surgical procedures since to remove affected muscle.
''SDHB staff failed to monitor and assess Mr A's pain appropriately, and a lack of critical thinking by SDHB staff led to a failure to investigate the cause of Mr A's ongoing pain adequately. This resulted in a delayed diagnosis of compartment syndrome.
''While I acknowledge that the individual health professionals who provided care to Mr A bear some responsibility for these failures, I consider that SDHB is ultimately responsible for the failures by multiple staff members to monitor, assess, and investigate the cause of Mr A's pain appropriately.''
In response, the health board was improving staff communication, pain monitoring, and staff education.
Mr Hill has told the board to apologise to the patient.
Acting chief medical officer Dick Bunton told the Otago Daily Times the problem should have been picked up because it was a reasonably common complication.
''We should have done better, there's no denying that.''
''[Compartment syndrome is] not an uncommon thing to be looking for - it's something that should be on your checklist for someone who has had an injury such as this person had.''
Mr Bunton said the correct systems had been in place, but no-one acted on the clinical signs at the right time.
