Man dies after scanty check

GP admits, after watchdog’s finding, to ‘missing opportunity’ for lifesaving intervention

Adoctor failed to properly examine an elderly man who presented with abdominal cramps and died just two days after being discharged, the Health and Disability Commission (HDC) has found.

The general practitioner (GP) involved has accepted the findings and regretted that he had “missed an opportunity” for further intervention, potentially compromising the patient’s “continuity of care”.

The man, in his 70s and referred to as “Mr A” to protect his privacy, contacted an after-hours phone triage service one morning in late 2017 as he had not felt well for two days.

The consultation report noted Mr A’s symptoms were: “Vomiting, personal context, abdominal pain,” and advised referral to the GP on call, referred to as “Dr B”.

Mr A had several long-term health conditions, including diabetes, cardiovascular disease, chronic renal failure, hypertension, and a hernia.

When he attended the after-hours GP clinic he reported vomiting and abdominal cramps, but the GP did not examine his abdomen.

It was noted in the report that he arrived in a mobility scooter and stayed in it during the consultation.

The GP concluded the man had a mild gastric upset, and sent him home, advising him to return if symptoms persisted.

The man’s health continued to deteriorate and he died two days later of complications from a bowel obstruction, before an ambulance called could arrive.

The man’s regular GP attended Mr A at his home after he died, and noted in the clinical notes: “[I]t would appear nobody examined [Mr A’s] abdomen. He was uncomfortable yesterday and still nauseated and vomited and did not want to eat.”

Speaking to the coroner, Dr B said he only found Mr A to have “mild abdominal cramps”. He also did not have access to the man’s full medical history, and the man never mentioned he had a hernia.

A report released yesterday by commissioner Anthony Hill found the after hours GP in breach of the Code of Health and Disability Services Consumers’ Rights for failing to appropriately examine and assess the man after he presented with cramps.

Hill recommended the GP apologise to the man’s wife, arrange an independent audit of his clinical notes to check that appropriate records have been made, and undertake further training.

He also recommended the medical centre report back to HDC on the implementation and effectiveness of the changes it has made as a result of this investigation.