It has also been ordered to apologise to the woman’s family.
The woman, in her 20s, went to the emergency department with worsening abdominal pain, vomiting and an increasing CRP (a protein made in the liver), showing signs of infection.
On her third visit to ED, a CT scan found that her small bowel lacked blood supply and was significantly compromised.
Her condition was deemed non-survivable and she later died.
Health and disability commissioner Morag McDowell considered the issue was not the failure to diagnose the woman’s condition correctly, but the failure to investigate the cause of the symptoms fully, given her increasingly deteriorating clinical picture.
That included the failure to review the woman’s latest blood test results before discharging her, the failure to seek a general surgery review of the woman during her second admission, and the failure by multiple clinicians to provide and document adequate safety-netting advice to the woman when she was discharged.
‘‘I acknowledge the difficulty in making the diagnosis of the woman’s ischaemic bowel, especially in the context of her young age, high BMI and immunosuppression,’’ Ms McDowell said.
‘‘However, I consider there were missed opportunities at the woman’s first and second presentations for SCDHB to investigate her condition thoroughly.’’
She said those opportunities might have led to an earlier diagnosis and intervention, but it could not be said with any certainty that the woman might have survived.
The commissioner’s recommendations included that the SCDHB. —
- Use an anonymised version of the woman’s case as a basis for staff training.
- Create guidelines on documentation covering various aspects of a patient’s journey through ED.
- Consider developing a consensus between ED specialists, physicians and surgeons at SCDHB for management of patients with acute abdominal pain.
- Provide a written apology to the woman’s family.
She also recommended the ED consultant complete a clinical notes audit with the Royal New Zealand College of Urgent Care.
