A doctor failed to properly examine an elderly man who presented with abdominal cramps and died just two days after being discharged, the Health and Disability Commission (HDC) found.
The general practitioner (GP) involved has accepted the findings and regretted that he had "missed an opportunity" for further intervention, potentially compromising the patient's "continuity of care".
The man - in his 70s - and referred to as "Mr A" to protect his privacy - contacted an after-hours phone triage service one morning in late 2017 as he had not been feeling well the previous two days.
The consultation report noted Mr A's symptoms were: "Vomiting, personal context, abdominal pain," and advised referral to the GP on call, referred to as "Dr B".
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Mr A had several co-morbidities, including diabetes, cardiovascular disease, chronic renal failure, hypertension, and a hernia.
When he attended the after-hours GP clinic he was experiencing vomiting and abdominal cramps, but the GP did not examine the man's abdomen.
It was noted in the report the man arrived in a mobility scooter and remained in it during the consultation.
The man had several long-term health conditions, including diabetes, cardiovascular disease, chronic renal failure, hypertension, and a hernia.
The GP concluded the man had a mild gastric upset, and sent him home advising him to return if symptoms persisted.
The man's health continued to deteriorate and he died two days later of complications from a bowel obstruction, before an ambulance called could arrive.
The man's regular GP attended Mr A at his home after he died, and noted in the clinical notes: "[I]t would appear nobody examined [Mr A's] abdomen. He was uncomfortable yesterday and still nauseated and vomited and did not want to eat."
Speaking to the Coroner, Dr B said he only found Mr A to have "mild abdominal cramps". He also did not have access to the man's full medical history, and the man never mentioned he had a hernia.
"I concluded that he seemed to have a mild gastric upset, possibly from viral origin and in the absence of red flags, I then explained my findings to him … and advised him to return for review should his symptoms persist, change, worsen or if new symptoms emerged," the GP told the Coroner.
But a report released today by Health and Disability Commissioner Anthony Hill found the after hours' GP in breach of the Code of Health and Disability Services Consumers' Rights (the Code) for failing to appropriately examine and assess the man after he presented with abdominal cramps.
"Dr B missed an opportunity to provide further intervention to Mr A, and Mr A's continuity of care may have been compromised," the report said.
Hill said expected clinical practice was for the GP to conduct an abdominal examination.
The GP had also failed to record a provisional diagnosis for his findings.
"An abdominal examination was clinically indicated in this situation," Hill said.
"[The GP] missed an opportunity to provide further intervention to [the man] and [the man's] continuity of care may have been compromised."
Hill recommended the GP apologise to the man's wife, arrange an independent audit of his clinical notes to check that appropriate records have been made, and undertake further training.
He also recommended the medical centre report back to HDC on the implementation and effectiveness of the changes it has made as a result of this investigation.
The GP told the HDC he regretted not being more alert to possible causes of the Mr A's symptoms, and accepted in hindsight he should have performed an abdominal examination.
"I feel strongly that I missed an opportunity, and I would once more like to sincerely apologise to [Mrs A] and her family for my possible failing in the care of her husband."