TDHB, doctor ‘failed’ woman

Healthcare provider Te Whatu Ora Taranaki and a doctor have been ordered to apologise to the family of a woman who was discharged from the emergency department with a kidney stone diagnosis only to die in hospital three days later.

In a decision released this week, deputy health and disability commissioner Dr Vanessa Caldwell said the woman was failed by inadequate systems of the then Taranaki District Health Board (TDHB) and by a senior house officer working on the day she first presented.

The woman, called Mrs A in the decision, was in her 80s when she presented at the ED of Taranaki Base Hospital in 2019 with symptoms of severe right-sided pain in her lower abdomen.

In ED, Mrs A was found to have impaired left kidney function, a kidney stone in her right kidney that was causing a blockage, a possible urinary tract infection and abnormal vital signs.

However, she was discharged about five hours later with a diagnosis of a kidney stone.

Mrs A went back to ED three days later, where she died as a result of acute kidney failure and obstruction of the single functioning right kidney.

Caldwell’s decision followed a complaint investigation and found the failures ‘‘were the result of both an individual error in clinical decision-making, and an inadequate system within the ED, for which TDHB had responsibility’’. As a result, she found that both the TDHB, now called Te Whatu Ora Taranaki, and the senior house officer working that day were in breach of the Code of Health and Disability Services Consumers’ Rights.

Caldwell said the senior house officer should have recognised the seriousness of the woman’s condition and admitted her to hospital.

In addition, the ED did not have clear systems in place to ensure that everyone – senior house officer, consultant and the patient – knew which consultant was responsible for each ED patient, Caldwell said.

‘‘TDHB had overall responsibility for these system failures that contributed to the tragic consequences of this case,’’ she said.

Caldwell said the actions and omissions of the senior house officer to recognise the seriousness of the woman’s condition contributed to her being discharged from the ED inappropriately.

‘‘While the SHO was a junior doctor at the time of events, I note her significant prior experience. I consider my criticisms of her care for the woman were well within her capabilities.’’

As a result of the findings, Te Whatu Ora Taranaki and the senior house officer were both asked to provide a written apology to the family.

Te Whatu Ora Taranaki was also referred to the director of proceedings for consideration of further proceedings.

Caldwell also made multiple recommendations to Te Whatu Ora Taranaki, including developing a more formal system for consultant handover in ED. She also recommended the senior house officer undertake further training and the Medical Council consider whether a review of the officer’s competence was warranted.

Greg Simmons, Taranaki’s chief medical adviser, said Te Whatu Ora deeply regretted the circumstances leading to the death. The TDHB ‘‘undertook a thorough investigation of the case and a range of recommendations have subsequently been implemented to ensure that the chain of events that led to this tragic outcome does not recur’’.

‘‘We are working closely with the HDC [Health and Disability Commissioner] on their recommendations and remain committed to improving the quality of healthcare provided.’’