Wellington regional coroner Ian Smith is calling on Capital and Coast District Health Board (CCDHB) to review its CT scan guidelines after the inadequate care and subsequent death of an elderly woman.
Peri Whareti, 77, was taken to Wellington Hospital after a passerby found her lying on the side of
the road in suburban Johnsonville on December 7 last year.
She was released from hospital the following day, without an assessment of her medication or a CT scan.
Mrs Whareti was readmitted to hospital on December 10 after her family and a local GP became concerned she was sleeping a lot and suffering chronic headaches.
Two CT scans showed her brain was bleeding. She died in hospital on December 14.
In findings released today, Mr Smith said he was not satisfied with Ms Whareti's care.
He referred to traumatic brain injury guidelines and said a CT scan should have been ordered sooner.
"It is clear that an opportunity to carry out an earlier CT scan was lost on this occasion," he said.
"It cannot be stated however, in Ms Whareti's case, as to whether earlier intervention might have provided a different outcome but it may have."
CCDHB objected to one of the coroner's preliminary findings, saying that on her second visit, Ms Whareti was seen in a timely manner and her scan was performed urgently.
But Mr Smith said the circumstances over her two visits indicated urgent steps were needed.
He recommended CCDHB review its CT scan guidelines for those hospitalised as a result of a fall, particularly if they are on the blood thinning drug Warfarin or similar treatments.
He found that Mrs Whareti died from blunt force trauma after an accidental fall.
- NZPA
