The Hutt Valley District Health Board has been slammed by the Health and Disability Commissioner for neglecting to make frequent checks on a patient with breathing difficulties who was later found dead in his room.

The Hutt Valley DHB says it accepts the findings and has unreservedly apologised to the man's wife and family about the poor standard of care given to him.

The man, in his 70s, who had motor neuron disease, was admitted to hospital in 2015 because he was struggling to breathe. He had his own personal breathing machine.

Health and Disability Commissioner Anthony Hill has today criticised the care given to the man, saying his recorded levels should have triggered hourly observations.


Instead the man who was being observed overnight was left out of sight of the duty nurses and in a cubicle with the curtains closed around him.

Nurses checked the man at 7.10pm, 10.45pm and 12.10am and each time his score indicated he needed more frequent checking, but this did not happen.

When a nurse checked on him at 4am she found him unresponsive with his breathing mask off. He was unable to be revived.

In his findings, Hill said the man was not monitored adequately and the DHB did not follow its Early Warning Score policy because if it had the man would have been checked by nursing staff more often.

He also criticised the DHB for not having a policy in place for monitoring personal BiPAP machines.

"It is the responsibility of Hutt Valley DHB to have in place adequate systems to ensure that an acceptable standard of care is provided to consumers. This includes having appropriate policies, having working documents that accurately reflect those policies, and ensuring that the policies are complied with," Hill said.

Hutt Valley DHB general manager of quality, service improvement and innovation Debbie Gell said it had already made a number of changes recommended by the HDC including making its early warning scores (EWS) policy and chart more consistent and clearer to understand and updating its policy around the management of patients using personal breathing devices.

Nurses has also been given additional training in relation to the processes required around early warning scores and the use of personal breathing devices.