MidCentral DHB, a surgeon and a registrar have been reprimanded for their care of an elderly man who died while in hospital recovering from a knee joint replacement.

The 75-year-old man had previously had a large gastrointestinal bleed caused by the used of non-steroidal anti-inflammatory drugs like ibuprofen after he dislocated his hip.

But at an outpatient appointment with an orthopaedic registrar and a pre-admission clinic where he was assessed by a house officer and a consultant anaesthetist, no one reviewed his previous medical records or documented the gastrointestinal bleed.

His knee joint replacement surgery was done by an orthopaedic surgeon who had knowledge of the man and his history but the bleed was not recorded in a surgical checklist or report.


The anaesthetist was not made aware of his history and ordered post-operative pain relief, which included ibuprofen, with the surgeon's knowledge.

The surgeon reviewed the man and expected he would be discharged in a few days then went on leave without a documented handover.

The patient then started to deteriorate and two house officers reviewed the man and stopped the ibuprofen because they believed he had a peptic ulcer and renal impairment. They then called a medical registrar.

The registrar concluded that the man had sepsis secondary to pneumonia and acute kidney injury but did not record his examination findings or seek advice from a more senior doctor or plan any follow-ups.

A second registrar examined the man and found he was seriously unwell with chest sepsis and renal injury and contacted a consultant who agreed he needed to be moved to intensive care.

The transfer was arranged but then the man went into cardiac arrest. CPR was performed but because of multiple organ failure doctors decided not to continue to resuscitate him and he died soon after.

Health and Disability Commissioner Anthony Hill found that the orthopaedic surgeon, the first medical registrar and Mid Central DHB failed to provide a reasonable level of care to the man.

He ordered they apologise to the family and made a number of recommendations to improve care.


Hill recommended the orthopaedic surgeon provide details to the commission on steps taken to formalise handover of his surgical inpatients to orthopaedic colleagues in the event of taking leave, to include a process of clear instructions for patient oversight.

He also recommended the first medical registrar provide evidence of undertaking further education in recognising the deterioration of a patient and the escalation of care to senior colleagues.

As for the DHB, Hill recommended it clarify roles and responsibilities of staff and outline precisely when in the patient surgical pathway, and by whom, the patient's clinical history and records were reviewed and communicated. He also recommended that the DHB detail ways for ensuring an appropriate medical response when a patient deteriorated and for ensuring junior doctors were confident and supported to go to senior colleagues with concerns about patients.