A woman in her 80s died after presenting to an emergency department (ED) and later being discharged with a kidney stone diagnosis.
The woman went to the ED with acute kidney failure, and her single functioning kidney was obstructed - but she was discharged with a diagnosis of a kidney stone. She returned to the ED three days later and died.
Dr Vanessa Caldwell, the Deputy Health and Disability Commissioner, said in a statement today that Taranaki DHB (now Te Whatu Ora Taranaki) failed "to provide services with reasonable care and skill" over the incident.
Caldwell said a senior house officer "should have recognised the seriousness of the woman's condition and admitted her to hospital".
"I consider the failures in this case were the result of both an individual error in clinical decision-making, and an inadequate system within the ED, for which the DHB had responsibility," she said.
Caldwell added the house officer was a junior doctor at the time, but said she had "significant prior experience".
"I consider my criticisms of her care for the woman were well within her capabilities," Caldwell said.
Te Whatu Ora Taranaki and the house officer have both been asked to apologise to the woman's family.
And since the death, Te Whatu Ora Taranaki has changed its processes, Caldwell added: "I am pleased to see the significant work and changes undertaken in the hospital to improve patient care to prevent a similar occurrence in the future."
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