Inadequate Assessment And Action Taken By Whanganui DHB’s Emergency Department

The importance of critically assessing patients when they
present to hospital on multiple occasions with the same
symptoms within a relatively short period of time, and
investigating symptoms fully and considering alternative
diagnoses was highlighted in a decision published by Deputy
Health and Disability Commissioner Dr Vanessa
Caldwell.

In her decision, Dr Caldwell found Whanganui
District Health Board (WDHB) in breach of the Code for
Health and Disability Services Consumers’ Rights (the
Code) for failing to provide services with reasonable care
and skill. She also referred them to the Director of
Proceedings to decide whether any proceedings should be
taken.

A Māori man in his 30s presented to Whanganui
DHB (WDHB) on five occasions over two months with a
recurring infection of the middle ear (otitis media). During
these presentations, clinicians did not undertake adequate
investigations to understand the extent of the disease, and
whether the man had developed complications from the otitis
media. Sadly, the man died as a result of a brain abscess,
which is a rare but known complication of untreated otitis
media.

Dr Caldwell considered the man received
inadequate assessment and action in the Emergency Department
(ED), including omitting to perform a CT head scan and not
following up abnormal test results adequately.

Dr
Caldwell noted DHBs are responsible for the services
provided by their staff, and “the clinicians involved in the
man’s care failed to appreciate the significance of his
repeated presentations, and take into consideration his
history of poorly resolving symptoms, and the possible
presence of complications.”

“Given the number of staff
involved across multiple presentations, I consider that WDHB
must take responsibility at an organisational level for the
widespread failure in its service.

“These failures
meant diagnosis of complications arising from the man’s
otitis media was delayed, and I therefore find WDHB in
breach of the Code for its failure to provide services to
the man with reasonable care and skill.

“It is
important that ED staff ensure any suspected drug use is
ruled out, so the root cause of any symptoms (which may be
assumed to be due to drug use) can be explored fully,” says
Dr Caldwell.

Dr Caldwell recommended WDHB and a
medical officer provide a written apology to the man’s
whānau.

Dr Caldwell made multiple recommendations to
WDHB, including review and amendments of its ED on-call
policy and processes for recall of patients, protocols for
managing suspected drug use and provide training to staff on
documentation and WDHB’s expectations in relation to
management of suspected drug use, and undertake an audit of
positive blood cultures received by the ED to identify
whether timely follow-up occurred.

She further
recommended the medical officer undertake self-directed
learning on bias in healthcare; and reflect on his care in
this case relating to his suspicion of drug use and the
appropriate course of action, and his lack of documentation
of discussions and observations.

Dr Caldwell also
referred WDHB to the Director of Proceedings and stated that
she “had regard to the particular vulnerabilities of the man
and to the public interest in improving healthcare outcomes
for
Māori”.

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