The patient, dubbed Mrs A in the decision, was admitted to rest-home-level care at Kauri Lodge in 2018. She had several co-morbidities – the simultaneous presence of two or more diseases or medical conditions in a patient – including heart disease, angina, congestive cardiac failure, diabetes and chronic renal failure.
Mrs A had an advanced care plan and noted that she wanted to be told all the details about her condition and treatment and have a say in every decision about her healthcare. She noted that if she were dying, she wanted medications to help settle her and wanted her family around her.
In January 2021, progress notes indicate Mrs A was independent with her personal care. At the end of that month she was admitted to a public hospital for an operation to treat kidney stones and to place a kidney stent.
In early February, Mrs A was discharged back to Kauri Lodge, with instructions from the hospital doctors to take pain relief and antibiotics, see her GP regarding her breathing and inhaler, and attend a follow-up clinic in two weeks. There is no evidence a care plan was developed on her return or that her GP was notified.
On February 8, Mrs A approached a nurse because she was having trouble breathing. She told the nurse that after her surgery, she had noticed her asthma had worsened.
On February 19, she went to the public hospital for the removal of her kidney stent. There is no evidence a short-term care plan was developed on her return.
She experienced several other issues over the following weeks, including not feeling well, shortness of breath and sleepiness. In March that year, she slid out of bed and was found on the floor of her room twice.
On March 16, a nurse practitioner reviewed Mrs A and although recorded Mrs A was unable to complete sentences and did not want to get out of bed, Dr C did not perform a neurological assessment. Instead, his plan was for staff to monitor Mrs A’s behaviour and restart her on a drug to which she had previously responded well.
On April 7, Dr C made a referral for a CT head scan for Mrs A. The next day the CT referral was declined because she did not meet the criteria.
On April 12, a referral for a review of Mrs A was made to Dr C. Dr C told the Health and Disability Commissioner (HDC) he undertook a virtual consultation on April 12 because flooding was keeping him isolated 60km away. He noted Mrs A was deteriorating. Neither he nor the nurse in attendance recorded any notes because of problems with the computer system and its reliability in recording consultations. On April 15, Mrs A died.
Kauri Lodge acknowledged the death Mrs A and noted it appreciates the stress Mrs A’s “rapid deterioration and death has caused her family”. Kauri Lodge said Mrs A did receive appropriate bedside care throughout her care.
Dr C told HDC that in 2021, he was the sole practitioner at the rural health clinic, during a time when “Covid was rampant” and consultations were often in the carpark. Dr C offered his sincere condolences to Mrs A’s family.
Cooper said Kauri Lodge did not provide Mrs A with an appropriate standard of care and breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the code).
“In summary, I am critical that Dr C did not perform further tests and assessments during the consultations of [March 16 and 30]. Mrs A’s family was not consulted following the medical review [on March 30], although they were in New Zealand in March and had expressed their concerns about Mrs A. When Mrs A complained of being short of breath, further assessments were not considered during the [March 13] consultation to rule out other causes (such as congestive heart failure or exacerbation of COPD).
“In addition, I am concerned that on two occasions there are no recorded notes. However, I acknowledge that Kauri Lodge is situated in a remote rural area and had poor access to the internet and experienced constant IT crashes, which contributed to notes being lost. Accordingly, I do not find that Dr C breached the code.”
