Health and Disability Commissioner Morag McDowell found SCDHB had breached the Code of Health and Disability Services Consumers' Rights (the Code) in several areas when providing care to a woman in her 20s in 2019, according to a HDC decision released today.
McDowell criticised the DHB for failing to fully investigate the cause of the woman's symptom's the first two times she turned up to the ED with worsening abdominal pain, vomiting and signs of infection.
At times the woman has also been crying and screaming out in pain, her medical notes show.
It was not until her third visit to the ED - just days after the woman first presented to the ED in pain - when the woman was given a third CT scan and it was found her small bowel was significantly compromised.
She underwent surgery and it was discovered her small bowel appeared to have died due to a lack of blood supply. Her condition was deemed non-survivable and she died days later after life support was switched off.
While McDowell could not say for certain whether earlier intervention would have saved her life, she believed it may have led to an earlier diagnosis and intervention.
"However, I consider there were missed opportunities at the woman's first and second presentations for SCDHB to investigate her condition thoroughly."
The DHB was not criticised for its diagnosis of the woman's ischaemic bowel condition, particularly due to several complicating factors, rather for not fully investigating the worsening symptoms that led to it.
The specific failures included a doctor not reviewing the woman's latest blood test results before discharging her, another doctor failing to seek a general surgery review of the woman during her second admission and failure by multiple clinicians to provide and document adequate safety-netting advice to the woman when she was discharged.
SCDHB was ordered by the commissioner to make a written apology to the woman's family as well as using her case for staff training and developing guidelines covering various aspects of a patient's journey through ED.
She also recommended the ED consultant complete a clinical notes audit with the Royal New Zealand College of Urgent Care.
