An elderly man died from a brain haemorrhage after being given the wrong medication and an elderly woman was diagnosed with diabetes after her doctor failed to warn of her increasing increasing blood sugar level, the Health and Disability Commission has found.

In the first case an 82-year-old man was treated with thrombolysis in an emergency department following a suspected stroke, Commissioner Anthony Hill said in a report released today.

The house surgeon at the hospital where the man was diagnosed was unsure which drug to administer so contacted a larger hospital that his hospital's medical protocols were based on.

A miscommunication meant he was advised to use tenecteplase, instead of the correct drug, t-PA alteplas.


The patient then suffered a fatal brain haemorrhage.

"Tenecteplase should not be used for the treatment of stroke, and is used only for treatment of heart attacks,'' Mr Hill said.

Mistakes were made by staff at both hospitals, he said.

The house surgeon should have sought advice from his own hospital.

There was a series of missed opportunities through the systems and staff to catch what would become a fatal error, Mr Hill said.

The District Health Board - which has not been identified - apologised to the man's family and circulated its Learning Report from this case to all other boards in New Zealand.

In the second case a doctor failed to diagnose an elderly woman with diabetes, despite numerous blood tests indicating that would be the outcome from an increasing blood sugar level.

Deputy Health and Disability Commissioner Rose Wall said the woman visited her GP several times over 20 months.

The GP repeatedly ordered blood tests for the woman, the results of which indicated that the woman was at high risk of diabetes or glucose intolerance.

The doctor failed to appropriately follow up the results, or inform the woman of them, Ms Wall said.

The woman's condition continued to deteriorate and she was hospitalised, at which point diabetes was diagnosed.

``The GP's overall management of the woman's blood test results led to a significant delay in her diagnosis of diabetes and, therefore, a delay in her access to appropriate treatment.''

His failure to inform the woman of the results meant that she was unable to make lifestyle decisions that may have improved her health, Ms Wall said.

The doctor apologised to the woman and her family and conducted a clinical audit of his practice.

Ms Wall also recommended that the Medical Council of New Zealand review the GP's competence to practise, and referred him to the Director of Proceedings.