A 68-year-old man died after four different doctors "failed to do the basics" and pick up on his congestive heart failure.
Palms Medical Centre, located in Palmerston North, and one of its GPs has been found in breach for failing to facilitate co-operation between doctors, with multiple medical staff "not thinking critically" to diagnose the man correctly, Health and Disability Commissioner Anthony Hill said.
During a one month period in 2018, the patient - who has not been named for privacy reasons - presented to the medical centre five times with shortness of breath and chest pain.
Although he was enrolled with a specific general practitioner, the man saw four different doctors over this time.
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Hill said each doctor treated him symptomatically, failing to apply critical thinking to his presentations, and put the man's symptoms down to his chronic obstructive pulmonary disease (COPD).
"They also failed to do the basics, such as reviewing [his] previous medical notes and undertaking thorough assessments," Hill said.
As a consequence, there was a delay in the patient being diagnosed with congestive heart failure, and even when the correct diagnosis was made, its severity was greatly underestimated, Hill said.
Despite being told that taking him to hospital was "unnecessary", and that his heart failure would show improvement with fluid restriction and medication, the man's daughter decided to take him to hospital.
He was admitted with a primary diagnosis of congestive heart failure and transferred to the Coronary Care Unit, but deteriorated and died the next day.
After the HDC investigation, Hill recommended The Palms Medical Centre meet with all its staff who were involved in the management of the man to discuss the findings of the report and its response.
The clinic were asked to arrange an independent review of its policies and procedures with a key focus on continuity of care.
They were also told to provide the family with a letter of apology.
The Palms acknowledged that the issues raised by this complaint relate to practice systems as well as individual doctor's clinical actions.
The Palms said that the practice has always been mindful of the importance of continuity of care.
It told HDC that over the past six or seven years the practice has looked at various strategies to try to manage patient demand.
Unfortunately it was impossible for any practice to guarantee that patients would always be seen by the same GP, a clinic representative told the commissioner.
One of the doctors who was found in breach told HDC that the practice had taken a number of learnings from this case, and the recommended changes had been put in place.
A copy of the report with details identifying the parties removed, except The Palms Medical Centre Ltd and the expert who advised on this case, will be sent to the Medical Council of New Zealand.
The Palms Medical Centre has been providing medical care to the residents of and visitors to Palmerston North and the surrounding regions of the lower North Island for nearly 25 years.
More than 17,300 patients are enrolled at The Palms, which has 15 doctors and 33 nurses.
Its clinicians provide over 50,000 routine patient consultations and 35,000 Urgent Care consultations, 20,000 nurse consultations per year, plus over 20,000 immunisations.