A patient who died after a nose-bleed was one of the 520 medical mistakes or other "adverse events" reported by district health boards for the 12 months to June.

The patient, whose name and gender are not stated, died at home following treatment by the Counties Manukau District Health Board.

"Staff underestimated the amount of blood the patient lost while in the ED [emergency department]," according to a brief note by the board in its annual report, along with all DHBs, of adverse events suffered by patients.

"When patient returned to acute [ear, nose and throat] clinic after first discharge, the registrar did not seek advice from a consultant."


"Instructions regarding what to do if the bleeding started again were given verbally only and the patient's spouse had not fully understood them."

The case was discussed at the DHB's "morbidity and mortality grand round" - a secretive session of doctors held regularly at all hospitals to discuss mistakes - in July.

The DHBs report their adverse events to the Health Quality and Safety Commission, which said today there had been five fewer reported in 2015/16 than in the preceding year.

Non-DHB health care providers reported 154 adverse events.

The largest single category of DHB adverse events involved clinical management - 245 incidents - followed by falls causing serious harm, 237 incidents; with medication-related events, at 21 incidents, accounting for the third-greatest number.

Adverse events reported by the DHBs include:
• Delay in treatment of a patient with sepsis (serious infection).

• A patient suffered an airway after eating, and died.

• A delay in delivering a baby by caesarean section contributed to its death.

• The wrong tooth was pulled from a dental patient.

• A swab wasn't removed, necessitating a second operation.

• The wrong patient was given an MRI scan

• A failed surgical abortion probably caused major fetal abnormality due to the medication used during the procedure. The outcome of the case is not clear in the DHB's report.

• Delayed treatment for spinal cord compression causing a patient to become paraplegic.

• Blindness occurred in a patient's eye due to delayed treatment for diabetic eye disease. A clerical error was blamed.

• A patient with a tear within the walls of the aorta artery was misdiagnosed as having gastritis and died suddenly.

• The wrong side of a patient's spine was operated on, in a procedure to remove part of a spinal disc.

• Staff did not recognise the positive result for an antibiotic-resistant superbug in a post-stroke patient transferred from Australia. Three other patients caught the bug. Staff were unfamiliar with the acronym CRE, which stands for carbapenem-resistant enterobacteriaceae.

Counties Manukau
• A surgical wound drainage tube was discovered in a patient three years after surgery. It had caused repeated infections and remained undetected in the chest wall as it was not visible on x-ray or ultrasound.

• Two patients suffered vision loss due to delays in follow-up appointments that were blamed on short-staffing.

Bay of Plenty
• The wrong skin lesion was removed from an anaesthetised patient's leg.

Hawkes Bay
• A patient suffered loss of vision from delayed treatment.

Hutt Valley
• A dental patient had the incorrect tooth removed.

• A baby died in the uterus of an acutely ill mother. Senior doctors were found to have supervised junior medical staff inadequately.

Nelson Marlborough
• Nine cases were reported of visual loss following delays in follow-up or treatment caused by increasing demand not being matched by staff numbers.

• A chest abnormality found unexpectedly on an x-ray was reported to the referring doctor, but not to the chest clinic. The patient had cancer and died. "We have had a poorly integrated patient radiology reporting system and IT radiology imaging systems," the DHB said.

• Thirty patients suffered loss of vision. Two cases were linked to problems with follow-up appointments and work-load and the other 28 are under investigation.