The wife of a man who died two days after allegedly inadequate medical care in South Otago says the mistakes made before his death were not good enough.

Given ''the evidence as to the inadequacy'' of the medical assessment he received, the death of John Douglas Mitchell on November 6, 2017, has been referred to the Health and Disability Commissioner by coroner David Robinson.

Robinson's coronial finding released yesterday found the care given to the 73-year-old retired Owaka farmer to be ''wanting''.

Mitchell died at home just two days after seeking medical help from an after-hours general practitioner at Clutha Health First general practice.


Christine Mitchell said yesterday she did not feel anger towards the doctor who saw her husband because he was ''really quite sick'' at the time of his death.

But she did not want the mistakes that were made at the time to be repeated.

''The only thing is: I was just hoping it wouldn't happen to somebody else,'' Christine Mitchell said.

''It's not really good enough, really.''

On November 4, 2017, Mitchell was seen by Dr Nico van Egmond after three days of feeling unwell.

He died two days later from blood poisoning, after vomiting faecal matter, and should have received an abdominal examination that would have revealed a ''substantial'' hernia that incorporated his penis and scrotum, Robinson wrote.

Robinson recorded Mitchell's cause of death as ''septicaemia secondary to aspiration pneumonia in the context of bowel obstruction''.

He should have received an abdominal examination and ''urgent admission to hospital''.


When Mitchell died he ''was not a well man'', Robinson wrote. At the time of his death, he suffered from a host of conditions, his mobility was limited and he was dependent on a scooter.

''I immediately recognise Mr Mitchell's comorbidities, and the uncertainty of outcome even if he had been a surgical candidate. It cannot therefore be definitely said that his death would have been prevented, but it is clear that an opportunity was lost.''

When Mitchell went to the after-hours general practitioner he was having abdominal cramps and had vomited that morning after not having eaten, nor having had a bowel movement, for two days.

He was thought to have a ''mild gastric upset'', possibly a virus. He was sent home with anti-nausea medicine and told to return to the doctor if his symptoms persisted.

Two days later, after returning from the toilet, he slumped forward and became unresponsive.

Mitchell was pronounced dead by ambulance staff.

A nurse who attended noticed he had vomited faecal matter. His regular doctor expressed concern.

And because the cause of death was unknown it was referred to the coroner.

In his report, Robinson noted ''the doctor frankly acknowledged that the care afforded to Mr Mitchell fell short of what would be expected''.

The doctor expressed ''shock, shame and embarrassment'' and offered an apology to Christine Mitchell and her family if they felt he had failed them, Robinson wrote.

Clutha Health First chief executive Ray Anton said to date the organisation had not been contacted by the Health and Disability Commissioner's office, ''but we will be fully co-operating with its investigation''.

''Until the time that the [Health and Disability Commissioner's office] releases its final report we will not be making any further statements,'' he said.