A woman who died days after undergoing bowel surgery deserved better post-operative care from the Nelson Marlborough District Health Board, the Health and Disability Commissioner has found.

In findings released today, Health and Disability Commissioner Anthony Hill said the hospital should have reacted more quickly to signs the 65-year-old was deteriorating following surgery and provided treatment which could have saved her life.

The woman had a high white cell count and was showing signs of obstruction of the bowel not long after undergoing bowel surgery in 2014.

However, it was not until five days after surgery that she was diagnosed with acute respiratory distress and transferred to ICU. She died hours later.


Hill found the DHB failed to pick up the earlier signs and therefore did not provide the appropriate treatment quick enough.

He said the hospital should have investigated whether the high white cell count was a sign of infection and criticised staff for not considering the possibility of inserting a nasogastric tube on the morning that the woman was transferred to ICU with breathing problems.

"Given the woman's known problems, it appears that inserting a nasogastric tube should have been considered at this time to treat the issues stemming from her ileus and respiratory distress, and I am concerned that this did not occur," Hill said.

Further concerns about the care she received while in ICU were also raised and found there had been a delay in escalating her care to the consultant anaesthetist.

He also found that invasive ventilation should have been implemented sooner when it was clear that the woman was experiencing severe respiratory failure.

In response to the findings that Nelson Marlborough District Health Board was in breach of the Code of Health and Disability Services Consumers' Rights, the DHB has provided a written apology to the dead woman's family.

It has also produced new clinical guidance on non-invasive positive pressure ventilation and provided the commissioner with a copy.