A man in his 70s died four days into a hospital stay after a consultant surgeon failed to recognise his deteriorating condition following a bowel perforation.
A consultant surgeon involved in his case has been criticised by Health and Disability Commissioner Morag McDowell.
The man, who had a number of health issues, was admitted to his local DHB in 2018. He underwent a colonoscopy where a number of polyps were removed.
The day after the procedure he returned to the hospital with abdominal pain and an x-ray showed his bowel had become perforated.
Because of the man’s many health issues staff at the hospital decided he should be treated at a larger hospital in another health district.
When the man arrived, surgeons decided to treat his condition conservatively due to his medical conditions.
Over the next two days, the man's condition worsened and on the third day, a consultant surgeon failed to recognise this, deciding to maintain the conservative treatment.
On the fourth day, the man's condition had deteriorated to the point where he was rushed into surgery.
It was found that his bowel had undergone extensive faecal contamination from a small hole. He died soon after the operation from septicaemia.
The Health and Disability Commission (HDC) has found the consultant surgeon, who assessed the man on day three, was in breach of the Code of Health and Disability Services Consumers Rights.
Morag McDowell, an HDC commissioner, acknowledged the decision to treat the man conservatively was "cautiously appropriate" due to his already poor health.
However, she believes that there was a missed opportunity to recognise the man's deteriorating health and intervene with potentially life-saving surgery.
"I acknowledge that the signs of sepsis were subtle and non-typical. However, it is well documented in the clinical notes that in the preceding 24 hours, the man had multiple reviews indicating that he was not well," McDowell said.
"Based on this, and the expert evidence, a deterioration in the man’s condition is evident."
McDowell noted that it was the responsibility of the consultant surgeon to elicit information about the man's condition from his junior colleagues.
The DHB was found to not be in breach of the code as the man's death was a result of an individual clinical judgement. McDowell also criticised some aspects of the man's care in general, referencing the delayed medical review, documentation and escalation of care a judgement.
The HDC has recommended that the consultant surgeon provide a written apology to the man's family.
McDowell also recommended that the larger DHB provide better training on documentation to its junior staff and training on escalation following multiple reviews of a patient. She recommends that it provide regular updates on progress in training.
Recommendations were also made to the man's local DHB, requesting that the larger DHB help to upskill their endoscopy service in polypectomy technique and assessment of polypectomy sites.
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