A raft of mistakes at Tauranga Hospital led to the misdiagnosis of a patient who later died, the Health and Disability Commissioner has found.
The findings of a damning report, released yesterday, revealed the Bay of Plenty District Health Board failed in its duty to provide an appropriate standard of care for the patient.
It said inadequate records, and inconsistent and flawed clinical handover processes by staff involved in the woman's care breached the Code of Health and Disability Services Consumers' Rights.
Doctors failed to diagnose an abdominal hernia with bowel obstruction, and the woman died of a brain injury suffered during a cardiac arrest at the hospital.
The commissioner and the health board refused to name the patient and the medical staff involved.
The report by commissioner Anthony Hill said the fit and active 78-year-old woman was admitted to hospital in mid-2010 with vomiting, dehydration and a groin lump.
She was reviewed by a junior registrar and a medical consultant who diagnosed an abdominal malignancy.
The next day she was reviewed by the junior registrar alone, as the consultant was working elsewhere.
The junior registrar spoke with the patient's GP, who queried that the cause for her vomiting had not been found, but the junior registrar did not pass these concerns on to the consultant, or give a handover to weekend staff.
She was not reviewed for 27 hours, during which time her condition deteriorated and she continued to vomit, with her husband emptying the containers himself because nurses were not available often enough.
Her condition was reviewed by a house officer on Saturday night, and pneumonia diagnosed.
The house officer noted he had been asked to see her earlier in the day, but it was one of the busiest days he had ever worked. As the hospital was full, she was moved to a surgical ward accepting medical overflow patients, but because the nurse was on a tea-break no handover was given.
That evening her condition rapidly deteriorated. Nurses paged a house officer at 9.30pm but she was not seen until 11pm. At 11.30pm she went into respiratory arrest and then cardiac arrest. She was transferred to the Intensive Care Unit, and the next day the hernia was diagnosed during surgery. However, she had suffered a severe hypoxic brain injury during the cardiac arrest, and died a few days later.
Board chairman Phil Cammish said it had addressed the concerns highlighted in the report and had implemented a number of changes, including a complete review of the Assessment Planning Unit, reinforcing documentation requirements by staff, including completion of clinical records and fluid balance charts, and reinforcing the need for junior medical staff to contact senior clinicians with any doubts or concerns.
The registrar no longer worked at the DHB but the consultant continued to work there, Mr Cammish said.
Asked if either staff faced disciplinary action, Mr Cammish said: "The DHB believes in having an open disclosure process for errors promotes the ability for staff to learn and not repeat the same mistakes. A blame-based environment does not do this and can result in the potential for errors to be repeated and further harm to be caused."
However, the DHB had apologised to the woman's family twice - first at the time then more recently at the commissioner's request. The registrar and consultant also wrote apology letters to the family.
The commissioner found the consultant failed to ensure he was adequately informed of the patient's history, and failed to consider a hernia with bowel obstruction as a possible diagnosis.
The registrar had failed to take an adequate history and failed to report that and the GP's concerns about a possible hernia to the consultant.
The matter has been referred to the coroner.