The 68-year-old woman — referred to in court documents only as "Mrs A" — died of massive cardiac arrest in November 2019 after 18 hours in hospital during which her care at times was severely lacking.
The Health and Disability Commissioner (HDC) released a scathing review a year ago and it was only the second case this year the director of proceedings elevated to the tribunal.
In a judgement released last month, Te Whatu Ora Health New Zealand did not object to a declaration being made that the Southern District Health Board (as it then was) breached regulations "by failing to provide services to the aggrieved person with reasonable care and skill".
Mrs A, who had previously been fit and well, saw her doctor after experiencing shortness of breath for five days.
The GP suspected a pulmonary embolism (a blockage in arteries that sends blood to the lungs), immediately administered blood-thinning medication and transferred her to hospital.
The patient’s blood work showed "significant heart strain" and within a couple of hours of being admitted a scan confirmed a large embolism.
A registrar who completed a handover for the respiratory team assessed her as at a intermediate-high risk of mortality.
Dr David Prisk, an expert who reviewed Mrs A’s treatment for the HDC, said her state was actually more precarious and the early misstep influenced subsequent decisions by medical staff.
At 7.30pm, five hours after admission, the woman’s symptoms placed her in the "red zone", which should have triggered a call to the senior medical officer.
It never happened.
And there were five further occasions over the next nine hours which should have prompted such a response and did not.
It was a "severe departure" from the acceptable standard of care, Dr Prisk said.
Under hospital protocols, thrombolysis (a procedure to break up blood clots) should have been considered and the respiratory consultant later admitted withholding it was a serious oversight.
Nearing midnight, Mrs A was transferred to the coronary care unit, after which there was a dearth of clinical progress notes.
On occasion, medication was given but not fully recorded, nor was it specified who administered it.
Dr Prisk believed the record keeping, which he said started with an inadequate admission note, was also a severe breach of standards.
By 6am the following day Mrs A continued to be short of breath and was anxious about her state, prompting a nurse to contact a house officer.
There was no documentation of the review that followed but it was clear there was still no alteration to her treatment plan.
An hour later, Mrs A’s daughter alerted staff to her mother’s loss of consciousness and that she could not be revived.
"SDHB acknowledges that there were multiple missed opportunities by SDHB staff to exercise sound clinical judgement and assess Mrs A’s deteriorating condition critically and to follow the DHB’s policy to escalate Mrs A’s care . . . and to communicate effectively with one another," group director of operations Hamish Brown said.
A spokeswoman for the HDC said before cases were taken to the Human Rights Review Tribunal, it considered: "seriousness of the breach, public interest, public accountability of the organisation, the setting of standards ... and the need for education to the sector and wider public."
