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Specialist support for medical staff in small public hospital (08HDC03994)

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(08HDC03994, 21 August 2009)

Public hospital ~ District health board ~ Support for medical staff in small public hospital ~ Senior medical officer review ~ Handover procedures ~ Rights 4(1), 4(5)

An 82-year-old man, who was known to have a history of heart and kidney problems, was admitted to hospital with symptoms of angina. Soon after admission, he developed symptoms of gastrointestinal bleeding. Following a sudden deterioration in condition, he was transferred to another hospital for further investigations.

Investigations were performed to check for gastrointestinal bleeding, but no source of bleeding was found. However, the man became increasingly confused and agitated over the next few days, and further tests were performed as his renal function deteriorated. The man's family were increasingly concerned about his condition, and arranged for him to be transferred to a large public hospital under the care of a renal specialist who had previously cared for him. Despite aggressive treatment, the man subsequently died.

It was held that the man's care was jeopardised by inadequate senior medical officer review and inadequate handover procedures. When his condition deteriorated he did not receive a prompt and appropriate response from clinical staff at the second hospital. In these circumstances, the district health board breached Rights 4(1) and 4(5).