A district health board has been asked to apologise and review its processes after a patient died following a failure by hospital staff to review his chest X-ray after surgery.

Health and Disability Commissioner Anthony Hill said the failure to review put Southern District Health Board in breach of the Code of Health and Disability Services Consumers' Rights.

The 87-year-old man was admitted to hospital in Southland with lower abdominal pain and vomiting black bile.

He was referred for surgery and removal of a gallstone, but his condition deteriorated that evening and the plan was made for the man to be admitted to the Intensive Care Unit post-operatively. He was taken to surgery urgently after a chest X-ray indicated aspiration pneumonitis.


During the handover to ICU, the anaesthetic team advised that the man would need a post-operative chest X-ray and that he was having oxygenation and ventilation problems.

The X-ray was done and a few hours later the ICU night team handed over duties to the ICU day team.

Neither teams reviewed the X-ray. That afternoon, the man died. The man's X-rays were reviewed for the first time at a multi-disciplinary radiology meeting the following day.

A large tension pneumothorax - which could affect normal breathing - was visible on his chest X-ray which had not previously been detected by any member of staff.

Mr Hill determined that the failure to review the X-ray was caused by a lack of clarity from Southern District Health Board regarding who was ultimately responsible for ordering and reviewing postoperative X-ray.

He said that in this case, individual clinicians "accepted a presumptive diagnosis" without having regard to the "bigger picture of the patient's presentation".

"All these issues were compounded by poor communication...which ultimately affected the quality and continuity of services provided to the man," Mr Hill said in his report.

Mr Hill recommended that the Southern District Health Board apologise to the man's family, review its processes regarding handover of care and responsibility of reviewing X-rays.