Woman died after doctors ‘too busy’

Wellington Hospital has been criticised for care failings after doctors were too busy to see a ‘‘desperately sick’’ elderly woman who later died of septic arthritis.

It took five requests and 32 hours before the woman was properly reviewed by the orthopaedic team at Capital & Coast District Health Board, by which time it was too late.

Health and Disability Commissioner Anthony Hill began his investigation after the woman’s daughter complained. The 88-yearold woman arrived at the hospital’s emergency department in 2010 with pain in her hip. She was initially diagnosed with musculoskeletal pain, and waited more than 11 hours to be transferred to a ward.

As the national target was six hours, this was ‘‘unacceptable,’’ Mr Hill said.

The next day, a junior doctor tentatively diagnosed septic arthritis. At that point the woman should have been reviewed by the orthopaedic team and had a hip aspiration. But a tussle between the orthopaedic and radiology departments ensued, with confusion over who should look at her first.

Despite being contacted several times by junior doctors, the orthopaedic team did not review the woman and advised that no antibiotics be given until radiology staff had looked at her.

Because of ‘‘a series of delays and miscommunications’’, between the orthopaedic and medical teams, nothing was done to ease the woman’s pain until Saturday evening, when antibiotics were given.

When the woman was finally reviewed by orthopaedics on Sunday morning, it was too late. She was diagnosed with septic shock and palliative care was the only option. She died a week later.

‘‘There were a number of failures that led to Mrs A receiving suboptimal care and treatment at the hospital,’’ Mr Hill said. ‘‘While individual health professionals must take some responsibility for the failures that occurred, the failures were largely a result of broader, systems issues at the hospital.’’

The district health board was found to breach the Code of Health and Disability Services Consumers’ Rights in failing to treat the woman in a timely way and in hospital departments failing to communicate properly with each other.

DHB chief medical officer Geoff Robinson said the hospital had apologised unreservedly to the family and did so again. There had been changes in processes to prevent a similar incident happening again.