An elderly man suffering from a advanced renal failure and sepsis died at an Auckland hospital after a delay in staff receiving his blood test results, the Health and Disability Commissioner says.
The 83-year-old was admitted to Franklin Hospital on a Saturday in mid-2008 suffering from four ulcers on his legs.
He was initially diagnosed with a chest infection, was prescribed antibiotics and a blood test was ordered for the Monday.
Over the next three days the man deteriorated, but it was not until his blood tests became available on the Tuesday afternoon it was discovered the seriousness of his condition, Commissioner Ron Paterson's report said.
The patient was rushed to Middlemore Hospital, but because of the advanced stage of his renal failure and sepsis, staff could only offer palliative care. The man died 48 hours later.
Mr Paterson said community hospitals needed to have systems to deal with unstable patients.
But he commended the Counties Manukau District Health Board on its "impressive and comprehensive response" to the man's case, including a new handover procedure which ensured more attention was paid to patients of concern.