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Assessment of severe back pain by GP and emergency department (07HDC14539)

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(07HDC14539, 12 December 2008)

Public hospital ~ District health board ~ Emergency department ~ General practitioner ~ House officer ~ Spinal abscess ~ Standard of care ~ Hospital overcrowding ~ Right 4(1)

A 25-year-old man presented to a rural physiotherapy clinic with back pain following an injury sustained while he was working on a farm. Over the following eight days, his back pain increased despite treatment provided by the physiotherapy clinic and his general practitioner, and he returned to the physiotherapy clinic in severe pain. He was prescribed alternative pain relief and an anti-nausea drug.

Shortly after this consultation, the man's partner persuaded him to travel to a large city hospital's emergency department for a second opinion. They arrived at the emergency department at 3.50pm.

The man was assessed by a senior nurse, who gave him medication for pain and nausea at 4.30pm.  At 5.25pm he was seen by a second-year house officer, who reviewed the nursing notes and examined him. Because the medication provided at 4.30pm had not relieved his pain, the house officer discussed his symptoms and treatment options with the emergency medicine consultant, who suggested giving the man intramuscular morphine, which was administered at 6pm. The man was advised about regular pain relief and told to return to the emergency department if there were any further concerns. The man returned home, where his condition deteriorated, and he died at about 7am the following day. A post-mortem conducted three days later by a forensic pathologist showed that the man died as a result of overwhelming sepsis from an untreated spinal abscess.

It was held that the public hospital failed to provide services of an appropriate standard by failing to adequately resource the emergency department, and failing to ensure appropriate supervision and effective guidance for staff, and an adequate documentation and discharge process. In these circumstances, the public hospital breached Right 4(1).

The care provided by the general practitioner and the house officer did not breach the Code.

This case highlights the threat that overcrowding poses to patient safety. Overcrowding does not excuse substandard care.