Southern coroner David Crerar has strongly criticised medical staff at Invercargill's Southland Hospital for ''serious failings'' in the way they cared for an elderly patient who died after surgery.
Edward Rabbidge (88), retired, of Edendale, a fit and active man who played golf regularly, had bowel surgery at Southland Hospital on February 21 last year.
He died of a heart attack in the hospital's surgical ward a week later.
A postmortem showed he had also suffered a massive unexpected post-operative bleed in his abdomen, made worse because he was on prescribed blood-thinning medication.
Mr Crerar said Mr Rabbidge was recovering well from his operation until the evening of February 28 when he complained of chest pains and began to deteriorate.
A locum doctor on the ward contacted the on-call surgical registrar, but it was later acknowledged the communication did not convey how seriously unwell Mr Rabbidge was.
His death was investigated by Southern District Health Board (SDHB) consultant surgeon Julian Speight, and by independent expert Dr David Knight.
In his report, Mr Speight said hospital staff had failed to correctly follow the SDHB's ''unstable patient scoring system'' when Mr Rabbidge became unwell.
A nurse should have contacted a house surgeon to review Mr Rabbidge and the review should have been discussed with a more senior doctor within a given time scale, but that did not happen.
However, Mr Speight said the abdominal bleed was a rare event and by the time Mr Rabbidge's symptoms were evident it was probably too late to save him.
Dr Knight said the medical response to Mr Rabbidge's deterioration was ''clearly inadequate''.
Despite him being obviously unwell, there was little intervention for over two and a-half hours.
The locum doctor should have recognised the gravity of the situation and ensured a senior doctor attended rapidly, he said.
Mr Crerar said Southland Hospital had ''acknowledged these shortcomings, accepted responsibility for them and given the appropriate apologies''.
All doctors, including locums, were now given a formal introduction to the ''unstable patient scoring system'' and how it was to operate, he said.
He directed that a copy of his findings be forwarded to the SDHB ''to ensure the lessons learned from the tragic death of Edward Rabbidge are not forgotten and are used as guidance for future enhancements to care''.
