Page Section: Skip Links
0 - A reference list of accessibility keys
1 - Home page
2 - Sitemap
3 - Search page
9 - Contact us
[ - Bypass the navigation and go to the main content of your current page
/ - newzealand.govt.nz
Skip to Page Header
Skip to Primary Navigation
Skip to Secondary Navigation
Skip to Page Content
Skip to Page Footer
Skip to Search
Page Section: Health & Disability Site Links
Health & Disability Commissioner - Te Toihau Hauoro, Hauātanga
Health & Disability Advocacy - Ngā Kaitautoko
Health & Disability Director of Proceedings - Whakawākanga
Page Section: Header
Health & Disability Commissioner - Te Toihau Hauoro, Hauātanga
Site map
Quick Search
Page Section: Primary Navigation
Home
About Us
Complaints
Decisions & Case Notes
The Act & Code
Education
Publications
Contact Us
Page Section: Breadcrumbs
you are here:
Home
>
Site Map
Page Section: All Page Content
Site Map
About Us
Wawata/Vision
History
The Commissioner
HDC Organisation Chart
HDC Consumer Advisory Group
Disability
Accessibility
Meet our team
Consumer Advisory Group
Making a complaint
Events
News and Updates
Health Passport
NZ Disability Strategy
United Nations Convention
Resources - Accessible formats
Useful Disability-Related Links
Contact Us
FAQs
FAQs - Consumers
FAQs - Providers
Utilities
Links
Current Vacancies
newzealand.govt.nz
Accessibility & Accessibility Formats
Your Rights
Site Map
Disclaimer
Privacy Policy
Copyright
Complaints
Complaints Resolution Overview
Making a Complaint
Self Advocacy
FAQs
Decisions & Case Notes
Commissioner's Decisions
Recently published decisions
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
By Occupation
Search Results
Commissioner Initiative Reports
Case Notes
Abnormalities missed during labour (07HDC15908)
Accidental overdose of morphine (05HDC05278)
Accuracy of wording of pathology report (04HDC02992)
Administration of unprescribed sedative (07HDC12369)
Allergic reaction to pharmacy-only medicine sold inappropriately (02HDC06951)
Anaphylactoid reaction following induction of anaesthesia (08HDC04573)
Antenatal and intrapartum care provided by midwife (05HDC17106)
Appropriateness and adequacy of scanning procedures and analysis of results during pregnancy (03HDC05925)
Asherman's syndrome and infertility due to complications of delivery (00HDC03447)
Assault of rest home resident (07HDC20395)
Assessment and documentation of deteriorating condition of rest home resident (03HDC13895)
Assessment and management of sepsis resulting in death (06HDC08129)
Assessment by midwife (07HDC14036)
Assessment following cervical manipulation (07HDC20616)
Assessment of 85-year-old woman for cataract surgery (03HDC13528)
Assessment of abdominal pain in an Emergency Department (06HDC08765)
Assessment of elderly man who developed septic arthritis (04HDC17230)
Assessment of man presenting to emergency department with back pain (03HDC10460)
Assessment of patient presenting with weight gain and abdominal discomfort, later diagnosed with large ovarian cyst (04HDC08095)
Assessment of severe back pain by GP and emergency department (07HDC14539)
Assessment practice at men's health clinic (08HDC02899, 08HDC05986, 08HDC07100, 08HDC09984)
Back manipulation by physiotherapist in presence of intervertebral disc injury (01HDC03073)
Breaking bad news after surgical procedure (01HDC00599)
Care and documentation relating to a woman with symptoms of pre-eclampsia (09HDC01311)
Care and treatment of abdominal and pelvic symptoms (05HDC00985)
Care and treatment of disabled person at emergency department (08HDC10486)
Care and treatment of patient with ongoing sore throat with unusual clinical presentation (05HDC12308)
Care of baby with Group B streptococcus septicaemia (04HDC04456)
Care of elderly man admitted to rural hospital with leg ulcers and diarrhoea (08HDC17125)
Care of elderly rest home resident with history of falls (06HDC16671)
Care of elderly rest home resident with neck fracture (05HDC06957)
Care of elderly woman with cervical fracture (05HDC09852)
Care of patient who suffered respiratory arrest secondary to upper airway obstruction from displaced dental plate (05HDC02988)
Care of patient with deteriorating vascular condition (07HDC14839)
Care of persistent leg condition in insulin-dependent diabetic (03HDC02828)
Care of pressure area in obese patient (07HDC18556)
Care of rest home resident (02HDC18190)
Care of rest home resident (05HDC18417)
Care of rest home resident (06HDC19526)
Care of rest home resident who sustained injuries from an unwitnessed fall (06HDC12434)
Care of rural hospital patient granted home leave with compromised lung function (07HDC11548)
Care of young woman with borderline personality disorder and depression (05HDC05329)
Care provided by community mental health services immediately prior to patient's suicide (08HDC08140)
Care provided prior to premature birth; appropriateness of decision not to resuscitate baby (03HDC13975)
Care provided to pregnant woman with cardiac problems (05HDC13401)
Care provided to rest home resident with dementia (02HDC16226)
Care provided to rest home resident with dislocated hip (06HDC06457)
Change in administration of feeding regime without consultation (02HDC08819)
Child consent to a vaccine (01HDC02915)
Child's death from postoperative haemorrhage after tonsillectomy (01HDC15000/02HDC00077)
Chiropractic management of elbow injury (07HDC17307)
Chiropractic management of lower back sprain (08HDC02247)
Circumcision of young boy at local medical centre (09HDC00810)
Clinical networking (09HDC01207)
Co-ordination of care of patient admitted to hospital with acute breathlessness (05HDC11908)
Co-ordination of discharge from hospital between medical and mental health teams (07HDC08795)
Communication between DHBs in relation to mental health care of itinerant patient (07HDC14286)
Communication between rest home staff and medical officer (07HDC09104)
Communication of significance of PSA test, and loss of referral (08HDC06165)
Complication following acupuncture treatment (07HDC12714)
Complications following abdominoplasty (07HDC07867)
Complications following bilateral breast reduction, abdominoplasty, and liposuction (03HDC05435)
Complications following insertion of suprapubic urinary catheter (07HDC15291)
Complications following knee joint replacement (06HDC09552)
Consent for surgery with an increased risk not known to the patient (07HDC11318)
Consideration of psychological factors for pain led to missed diagnosis of spinal abscess (01HDC03147)
Continuity of care for woman with delayed diagnosis of cervical stenosis and myelopathy (08HDC06359)
Counselling by text message (09HDC01409)
Damage to blood vessel during surgery, and inadequate information given to patient (02HDC10715)
Damage to major blood vessels during laparoscopic appendicectomy; failure to inform patient of nature and severity of complications (03HDC05563)
Damage to spinal accessory nerve during neck surgery performed after hours (03HDC06095)
Death after delay in receiving treatment for DVT in an Emergency Department (01HDC11475)
Death by cardiac arrest following transfer of care (99HDC10975)
Death caused by leaking anastomosis following bowel surgery (00HDC03311)
Death of 14-year-old boy one week after rugby injury (01HDC11702)
Death of a baby born with severe cerebral insult (02HDC01476)
Death of baby after delay in Caesarean section (04HDC04652)
Death of baby as a result of birth asphyxia after abnormal labour (01HDC05155)
Death of baby following obstructed home labour and delayed referral to specialist care (00HDC08628)
Death of baby following prolonged pregnancy (06HDC18721)
Death of baby from intracranial haemorrhage following trial of forceps delivery (00HDC09324)
Death of baby several hours after home birth (06HDC08238)
Death of infant from viral meningitis (02HDC05308)
Death of rest home resident due to necrotising fasciitis (07HDC17744)
Death of woman presenting with symptoms of headache and gastroenteritis (01HDC08153)
Death of young woman prescribed second-generation contraceptive pill despite history of superficial thrombosis (03HDC00837)
Delay in diagnosing cervical cancer and referring for treatment (03HDC15479)
Delay in diagnosis of streptococcal infection in patient presenting with back pain (04HDC20951)
Delay in diagnosis of thoracic aortic aneurysm (07HDC07977)
Delay in excision of rare malignant melanoma of the lip (01HDC11477)
Delay in identifying fetal distress during delivery (03HDC16282)
Delay in MRI during medical radiation technologists' strike (07HDC05942)
Delay in receipt of bowel cancer test results and referral for chemotherapy (00HDC12383)
Delayed diagnosis of ectopic pregnancy (00HDC08633)
Delayed diagnosis of perforated bowel and peritonitis (02HDC09815)
Delayed diagnosis of testicular torsion (04HDC00463)
Dental care of a child (05HDC13588)
Dermatologist performing cosmetic surgery did not warn of risk of scarring (00HDC10159)
Diagnosis and management of paediatric fever (09HDC01190)
Diagnosis and treatment of patient presenting with chest pain (04HDC00656)
Diagnosis of cardiac problem (07HDC20618)
Diagnosis of squamous cell carcinoma (04HDC20196)
Diagnosis, management and discharge of suicidal man (04HDC00671)
Difficulties experienced with hospice providing palliative care at home (00HDC11970)
Discharge from emergency department with undiagnosed bowel obstruction (01HDC04138)
Disclosure of confidential information obtained during doctor-patient consultation (01HDC04859)
Dislodgement of T-tube during postoperative period (07HDC19531)
Dispensing error (02HDC04619)
Dispensing error - antihypertensive (01HDC10717)
Dispensing error at community pharmacy (06HDC12613)
Dispensing errors (04HDC10718)
Dosage errors in dispensed medications (05HDC03953)
Emergency contraception - patient's needs and wants (98HDC16189)
Emergency department care and management of an incomplete spinal fracture (07HDC17769)
Episiotomy requiring repair (01HDC05191)
Error in administration of anaesthetic (02HDC05291)
Error in labelling of medications (04HDC11716)
Error in packaging and delivery of medication (04HDC15595)
Examination and investigation of ongoing urinary and abdominal discomfort (03HDC03134)
Extraction of all lower teeth instead of four as planned (02HDC18228)
Eye Department's management of urgent cases (00HDC09046)
Failure by hospital midwives to adequately detect and monitor neonatal hypoglycaemia, and to document a plan of care; failure of DHB to respond appropriately to a complaint (05HDC16723)
Failure of GP to follow up on results of referral for ultrasound, which patient was to arrange (01HDC08770)
Failure of hospitals to ensure that employee was competent to practise surgery (04HDC07920)
Failure of rest home to respond to complaints (05HDC04892)
Failure to address deteriorating condition of rest home resident (03HDC14664)
Failure to arrange hospital admission for post-partum woman with hypertension, who later suffered eclamptic seizures (03HDC15081)
Failure to diagnose breast cancer in a timely manner (01HDC04864)
Failure to diagnose hip fracture owing to inadequate physical examination (02HDC16966)
Failure to diagnose raised intracranial pressure after fall (01HDC11911)
Failure to diagnose subarachnoid haemorrhage (02HDC18871)
Failure to discontinue anticonvulsant before commencing ECT (00HDC07173)
Failure to discuss option of radical surgery for brain tumour (02HDC18414)
Failure to obtain relevant clinical information before reporting fine needle aspiration (98HDC16686)
Failure to provide information and obtain informed consent for anaesthesia (05HDC07699)
Failure to recognise hypoglycaemic coma and seek medical assistance (02HDC17106)
Failure to report medication error (06HDC10115)
Failure to report rest home resident’s fall (05HDC16647)
Failure to report the fall of a rest home/hospital resident or to follow correct lifting procedures (06HDC16618)
False positive reporting of prostate biopsy slides (08HDC07231)
Farmer treated for muscular pain and cholesterol died of heart attack (00HDC05372)
Financial exploitation by community care worker (09HDC01375)
Financial exploitation by Shiatsu therapist (02HDC18117)
Fire in airway during laser surgery (04HDC04340)
Fitting of veneers to teeth (03HDC16810)
Fluid overload following surgery (00HDC00231)
Foetal distress during labour not monitored by midwife on arrival at hospital (01HDC09138)
Follow-up advice to patient (08HDC07350)
Follow-up of abnormal urine test result in infant (04HDC08084)
Follow-up of patient test results (00HDC07636)
Force used on dementia unit patient (08HDC00477)
Gastric banding procedure did not produce desired weight loss (01HDC00755)
GP management of an exacerbation of chronic airways disease (01HDC11412)
GP management of child with gonorrhoea without involvement of sexual abuse specialists (01HDC01802)
GP overstated benefits of a treatment for chronic fatigue syndrome (01HDC02649)
GP's failure to detect breast lump during breast examination (02HDC08299)
GP's involvement as friend where patient cared for by another GP (00HDC08647)
GP's monitoring of patient during acupuncture treatment (03HDC03984)
Heart disease incorrectly diagnosed as viral infection (05HDC03782)
Hypertrophic scar after tattoo removal with radiosurgical technique (01HDC02274)
Identification of risks to thyroidectomy patient (09HDC01422)
Inadequate assessment and failure to document consultation (07HDC01315)
Inadequate diagnosis and treatment of patient in rest home (01HDC12197)
Inadequate documentation and standard of care (05HDC18619)
Inadequate documentation and standard of care during labour (07HDC03243)
Inadequate follow-up dental care and delay in referral to oral specialist (05HDC06970)
Inadequate follow-up of test results in patient with malignant lymph node (02HDC13523)
Inadequate gynaecological cosmetic surgery and lack of consent (05HDC09254)
Inadequate information and medical back-up for patient undergoing chemical face peel (99HDC12013)
Inadequate information prior to cosmetic procedure (07HDC05410)
Inadequate management of weight loss in elderly rest home patient (04HDC18516)
Inadequate monitoring of sedated patient (02HDC08692)
Inadequate newborn resuscitation technique and post-partum haemorrhage monitoring (07HDC08615)
Inadequate patient assessment and recommendation of transportation to hospital (03HDC00153)
Inadequate psychiatric assessment of patient with head injury (05HDC13239)
Inadequate radiology report and insufficient information given to patient (03HDC08493)
Inappropriate language and lack of respect for patient (09HDC01315)
Inappropriate massage and lack of informed consent (04HDC17805)
Inappropriate preoperative and postoperative charges for cataract surgery in a public hospital (05HDC12122)
Inappropriate prescription of Codeine Linctus to baby (99HDC01986)
Inappropriate prescription of medication to partner (06HDC14100)
Inappropriate relationship with client (08HDC14245)
Inappropriate relationship with client (08HDC17394)
Inappropriate relationship with client following discharge from care (05HDC16909)
Inappropriate relationship with patient (07HDC11761)
Inappropriate relationship with patient (07HDC19540)
Inappropriate relationship with patient (09HDC01342)
Inappropriate sexual behaviour with client (06HDC15791)
Inappropriate sexual relationship with a client (06HDC07873)
Inappropriate sexual relationship with a client (06HDC09325)
Inappropriate sexual relationship with a client (07HDC00101)
Inappropriate sexual relationship with a client (07HDC02711)
Inappropriate sexual relationship with a patient (06HDC01330)
Inappropriate sexual relationship with patient (06HDC18422)
Inappropriate technique used by chiropractor to treat back pain and sciatica (03HDC00910)
Inappropriate treatment by massage therapist (07HDC18827)
Inappropriate treatment by massage therapist (08HDC07644)
Incorrect identification of patient when dispensing methadone (06HDC17949)
Infant with Rhesus disease develops fatal haemolytic anaemia after discharge from hospital (07HDC10316)
Information about and informed consent for anaesthesia (09HDC01691)
Information about right to view ultrasound scans prior to abortion (09HDC00842)
Information and care provided to patient undergoing liver cancer treatment (09HDC00795)
Information and care provided to patient undergoing liver cancer treatment (09HDC01870)
Informed consent for child receiving vaccines (01HDC12269)
Informed consent in admitting respite care resident to rest home (97HDC9172)
Informed consent prior to anaesthetic procedure (07HDC08687)
Informed consent prior to massage therapy (06HDC12937)
Informed consent to innovative surgery (08HDC20258)
Informed consent to surgical procedure (08HDC08813)
Informing patient of risks of operation (98HDC19009)
Insensitive communication and discriminatory behaviour when reviewing HIV-positive patient for colonoscopy (03HDC13605)
Insufficient information and consultation to allow informed consent (98HDC15056)
Insufficient information given about possible complications of lipo-infiltration (99HDC00541)
Insufficient information provided to patient undergoing functional orthodontic treatment (03HDC03104)
Insufficient patient information to enable fully informed consent (03HDC19128)
Insulin dispensing error (02HDC07385)
Insulin dispensing error (07HDC21772)
Internal and external triage leading to delayed hospital admission (04HDC00658)
Internal resorption of tooth treated by apicectomy without standard root filling (01HDC07477)
Interpretation of breast biopsy specimens (02HDC08200)
Interpretation of mammogram and ultrasound scans (05HDC11656)
Intrauterine contraceptive device fitted to pregnant woman (03HDC16721)
Investigation of blood in urine missed diagnosis of rare heart tumour (00HDC06335)
Investigation of woman with melanoma and metastatic spread to liver (01HDC12788)
Kenacomb ear drops dispensed instead of prescribed chloramphenicol eye drops (04HDC08685)
Lack of assessment and management of suicidal patient (00HDC13101)
Lack of assessment and treatment of woman diagnosed with bowel cancer; inadequate record-keeping (03HDC11066)
Lack of communication during transfer of seriously injured patient (02HDC05825)
Lack of objective assessment and communication to hospital staff (99HDC02269)
Lack of timely notification of results indicating failed vasectomy (02HDC18949)
Lack of treatment planning process and record-keeping (02HDC12290)
Late diagnosis of abdominal tumour and DVT (04HDC14223)
Liver biopsies for research performed during surgery without consent (00HDC07593)
Loss of eyesight after delay in receiving eye surgery (01HDC13673)
Loss of referral between district health boards (07HDC20199)
Management of a rest home resident's care during a period of transition (08HDC04291)
Management of an undiagnosed breech delivery (08HDC10923)
Management of angulated radial fracture without manipulation (01HDC02275)
Management of bladder cancer (04HDC11624)
Management of cervical spinal injury (08HDC14166)
Management of couple treated for gonorrhoea by different GPs in same practice (01HDC03691)
Management of dementia resident’s behaviour and falls by rest home (09HDC01050)
Management of deterioration of rest home resident (02HDC15234)
Management of elderly patient and communication with family (07HDC01804)
Management of elderly patient over eight-year period (06HDC12164)
Management of elderly patient with pressure sores (04HDC08400)
Management of endometriosis in woman trying to conceive (04HDC03651)
Management of fetal distress by midwife (01HDC10714)
Management of fractured cervical vertebra (04HDC01638)
Management of head injury (07HDC10767)
Management of labour and birth using birthpool (04HDC01133)
Management of labour and delivery of baby with shoulder dystocia (06HDC02099)
Management of labour in light of CTG evidence suggesting fetal compromise (05HDC16711)
Management of labour, delivery and post-delivery care (03HDC10782)
Management of life-threatening asthma in young child (08HDC04311)
Management of patient following post-anaesthetic complications (01HDC02221)
Management of patient on methadone programme (05HDC09043)
Management of patient with severe, deteriorating mental illness (01HDC13687)
Management of raised blood sugar level (03HDC15092)
Management of referrals for specialist urological services (09HDC01040)
Management of rest home resident suffering from dehydration; communication with welfare guardian (08HDC20829)
Management of rest home resident’s fall; follow-up of PSA test (08HDC17309)
Management of rest home resident’s pain and falls (09HDC00987)
Management of stroke in Emergency Department (00HDC07869)
Management of thigh injury that progressed to osteomyelitis; communication with Samoan patient with limited English (02HDC04045)
Management of ventouse-assisted birth (06HDC12769)
Management of woman presenting with chest pain (05HDC00814)
Management of woman with upper gastrointestinal symptoms subsequently diagnosed as ovarian cancer (03HDC04996)
Management of work-related injury that progressed to cellulitis (03HDC02435)
Management of wound caused by glass (01HDC04614)
Management of young child with pulled elbow (01HDC01097)
Management of young man with Asperger's syndrome (00HDC12819)
Manner in which services provided at a public hospital (96HDC1760)
Medication dispensed at incorrect dose (04HDC10307)
Medication error contributing to patient’s death (03HDC14692)
Medication errors in a dementia unit (05HDC18726)
Medication errors; communication with the family of a rest home resident (08HDC20820)
Medication safety - prescribing errors (07HDC09719)
Meeting the needs of a disabled person in a residential care home (06HDC04441)
Midwife accidentally caused scald when warming baby's heel for Guthrie test (00HDC06573)
Midwife's management of labour of young woman who felt left out of "communication loop" (01HDC05774)
Misdiagnosis and premature discharge of elderly woman with shortness of breath (09HDC00865)
Misdiagnosis of acute heart disease as gastro-oesophageal reflux (04HDC11728)
Misdiagnosis of ectopic pregnancy and administration of methotrexate when pregnancy subsequently found to be intrauterine (02HDC10862)
Misdiagnosis of gastritis in patient with chest pain who subsequently died from myocardial infarction (03HDC01502)
Misdiagnosis of patient suffering from abdominal aortic aneurysm (04HDC12081)
Misdiagnosis of pyogenic abscess as hydatid cyst (01HDC07116)
Misdiagnosis of subdural haematoma as migraine (01HDC11439)
Mishandling of a change of mental health diagnosis, and failure to obtain a second opinion (07HDC06672)
Mishandling of ophthalmology referral (07HDC19869)
Missed diagnosis in patient presenting with sudden onset of headache (07HDC16428)
Missed diagnosis of advanced colorectal cancer (10HDC00253)
Missed diagnosis of breast cancer (05HDC05429)
Missed diagnosis of chronic peptic ulcer with long-term use of NSAIDs (01HDC09589)
Missed diagnosis of lung cancer (07HDC08819)
Missed diagnosis of ovarian cancer (01HDC00389)
Missed diagnosis of pneumonia in patient with dark bowel motions (00HDC05800)
Missed diagnosis of ulcerative colitis in young mother presenting with rectal bleeding (00HDC08356)
Missed early diagnosis of stomach cancer (02HDC08972)
Missed pelvic fracture on X-ray (03HDC14447)
Monitoring and recording of progress of labour by midwife (05HDC12098)
Monitoring of cellulitis by registered nurses in an aged care facility (05HDC07285)
Monitoring of deteriorating chest infection in an elderly resident of an aged care facility (05HDC15501)
Monitoring of deteriorating condition of respite care dementia patient in an aged care facility (07HDC17647)
Monitoring of established labour and fetal heart rate when meconium noted (03HDC15086)
Monitoring of health status of respite care resident (01HDC00072)
Monitoring of lithium levels and drug interactions (01HDC09132)
Monitoring weight loss in a disabled persons' residential care facility (07HDC07675)
Multiple dislocations following hip joint replacement (08HDC02404)
Multiple dispensing errors with repeat prescriptions but pharmacist could not be identified (01HDC11910)
No routine screening suggested to prevent sudden cardiac death of woman with diabetes (00HDC06972)
Non-compliance with lifting and transfer policy and failure to report incident (07HDC16959)
Nurses recorded postoperative deterioration without seeking medical review (00HDC04656)
Open disclosure following a surgical complication (08HDC08586)
Ophthalmology care and inadequate management of patient appointments (06HDC15893)
Overdose of paracetamol to acutely ill child (02HDC08949)
Overdose of testosterone administered to infant with congenital adrenal hypoplasia (04HDC03355)
Palliative care during norovirus outbreak (09HDC01783)
Patient care and quality assurance systems (Gisborne Hospital Report)
Patient unaware that addiction to benzodiazepines could develop in a few weeks (00HDC11568)
Perforation of uterus during insertion of IUCD (03HDC15569)
Pharmacist dispensed wrong medicine and did not provide information or privacy (00HDC03977)
Phenoxymethylpenicillin dispensed instead of prescribed flucloxacillin (04HDC13191)
Physiotherapy assessment, consent and documentation (06HDC16422)
PICC line for urgent antibiotic in rural setting (01HDC01820)
Placement in secure residential care (08HDC20957)
Poor management of fluid balance and failure to seek second opinion in patient deteriorating after hepatectomy (01HDC04847)
Poor wound care and documentation, and financial exploitation of rest home resident (08HDC08672)
Poor wound care and documentation, and financial exploitation of rest home resident (08HDC10236)
Postnatal care provided to woman with pyrexia (08HDC18402)
Postnatal management of perineal tear (05HDC13928)
Postoperative care of deteriorating patient in private hospital following abdominal surgery (06HDC13334)
Postoperative care of deteriorating patient in private hospital following gynaecological surgery (06HDC17645)
Postoperative care of patient with special needs (06HDC19538)
Postoperative management of laparoscopically assisted vaginal hysterectomy (09HDC00816)
Pregnancy counselling of 14-year-old girl (99HDC01345)
Preoperative and postoperative management of breast reduction surgery (05HDC10177)
Preoperative care of deteriorating patient following bowel surgery (06HDC09771)
Prescription and administration of Maxolon without complying with hospital policies (03HDC04005)
Prescription of anti-emetic to six-month-old baby (05HDC07953)
Prescription of antipsychotic medication inappropriate to patient with Parkinson's disease (03HDC06279)
Presentation of cholestasis in woman pregnant with twins (03HDC06196)
Presentation of infant with illness later diagnosed as meningococcal septicaemia (03HDC06973)
Prioritisation and management of patient requiring ENT and radiology services (09HDC00891)
Professional and ethical boundaries in a counselling relationship (03HDC16962)
Professional boundaries between a psychologist and a recent former client (07HDC08103)
Professional boundaries between caregiver and client (07HDC10991)
Professional boundaries in relationship with client (04HDC05983)
Provision of antenatal and labour care (05HDC01760)
Provision of co-ordinated services to mental health patient (07HDC16607)
Psychiatric assessment and granting of home leave (06HDC04783)
Radiologist did not obtain consent for registrar to observe ultrasound at teaching hospital (00HDC06794)
Rare neurosurgical emergency misdiagnosed as migraine (08HDC00248)
Rash erroneously attributed to codeine reaction when patient suffering from meningococcal disease (03HDC00575)
Recurrent surgery for varicose veins (07HDC13222)
Registrars miss uncommon diagnosis of ischaemic bowel in young woman (01HDC02515)
Relationship between a counsellor and former client of an alcohol and drug clinic (01HDC09143)
Relationship boundaries in providing joint marriage counselling (02HDC01167)
Relationship with former patient and what constitutes ongoing medical care (03HDC11070)
Repair of incisional hernia performed as a day procedure (07HDC00329)
Reporting of mammograms in woman who developed breast cancer (02HDC10479)
Retinal tear missed by optometrist who did not dilate pupils (00HDC09842)
Retired GP assists rest home resident in emergency (06HDC15897)
Review of dementia condition and medication regimen (04HDC10605 )
Risperidone dispensed instead of prednisolone (06HDC01037)
Roles and responsibilities in prioritisation for first specialist assessment (04HDC13909 )
Rural GP did not respond appropriately to urgent calls from district nurse (00HDC07870)
Rural house calls for patient with fractured ribs following fall (00HDC07631)
Sedation and inadequate care of patient in rest home (00HDC11595)
Severe facial pain a rare complication of surgery to remove a presumed tumour (00HDC09540)
Severe hypoglycaemic episode after deteriorating condition missed (07HDC04325)
Sexual and financial exploitation of client by chiropractor (02HDC09817)
Sexual encounter by psychologist with client while counselling client's partner (00HDC08029/00HDC10721)
Sexual misconduct by a physiotherapist (06HDC15374)
Sexual relationship between a counsellor and client (09HDC01937)
Sexual relationship with a patient (03HDC06091)
Sexual relationship with a patient (09HDC01403)
Sexual relationship with client (02HDC11760)
Sexual relationship with patient (07HDC03930)
Sigmoidoscope contaminated with blood of previous patient (01HDC01818)
Specialised bowel surgery performed by general surgeon in provincial hospital (07HDC17438)
Specialist care for young woman rapidly deteriorating with rare illness (01HDC11283)
Specialist support for medical staff in small public hospital (08HDC03994)
Spinal manipulation undertaken by massage therapist (07HDC03068)
Spiritual approach in GP consultation (03HDC19027)
Standard of care in an aged care hospital (08HDC15931)
Standard of care in dementia unit (08HDC17105)
Standard of care in relation to male dementia patient with sexualised behaviour (04HDC07008)
Standard of care of pressure sore (06HDC00079)
Standard of care provided by anaesthetist (04HDC11777)
Standard of care provided to incontinent rest home resident with pressure sores (96HDC3695)
Standard of dental treatment; informed consent (09HDC01081)
Standard of inpatient mental health services, Southland District Health Board (01HDC11139)
Standards of care not met in bowel surgery (02HDC14836)
Stroke a rare complication of neck manipulation by osteopath (02HDC11987)
Support for mental health consumer in the community (08HDC05072)
Surgeon, theatre nurses and hospital failed to prevent wrong-site surgery (00HDC06857)
Surgical emergency missed by locum casualty officer and overworked surgeon (02HDC08734)
Surgical error during laparoscopic cholecystectomy (08HDC03361)
Surgical prioritisation and care of patient with acute appendicitis (09HDC00836)
Surgical standards and postoperative management of radical prostatectomy (05HDC18424)
Taking care in after-hours calls (98HDC15681)
Teeth whitening supplied by an unregistered non-dentist whitening practitioner (09HDC02164)
Theatre incident resulting in corneal burns (06HDC00096)
Tooth extraction recommended and performed without appropriate consent when restorative work an option (03HDC13742)
Trandate dispensed instead of prescribed tramadol (04HDC11276)
Transfer to secondary services after prolonged second stage of labour (07HDC16053)
Traps in repeat prescribing (99HDC01756)
Treatment by physiotherapist of farmer's shoulder injury requiring surgery (02HDC07420)
Treatment of anaphylaxis at an accident and medical clinic (06HDC12322)
Treatment of gastrointestinal symptoms (06HDC11343)
Treatment of significant tooth decay in young, anxious child (00HDC12109)
Unacceptable delay in providing patient with results of spinal X-ray (03HDC02380)
Unbalanced information to patient leads to major surgery to remove liver cyst (01HDC05619)
Unsuccessful laparoscopic sterilisation surgery (07HDC03504)
Use of alternative therapy to treat breast cancer (08HDC00218)
Use of hoist when transferring rest home resident (08HDC00469)
Vertebral artery dissection following neck manipulation by osteopath (03HDC09752)
Waiting time for CT scan for patient with symptomatic cerebral aneurysm (07HDC11036)
Warfarin administration in a rest home (07HDC11952)
Warfarin dispensing error (03HDC13660)
Wisdom teeth extraction with postoperative pain and complications (01HDC13700)
Woman with splenectomy died postpartum of overwhelming infection (00HDC06473)
Wound care provided to a rest home resident (07HDC12520)
Wound care, documentation and consultation with family (09HDC01035)
Written consent to hysterectomy considered conditional on surgical finding of ovarian cancer not severe endometriosis (00HDC08358)
Young man with abnormal ECG sent home and died of a heart attack (02HDC01833)
Young woman committed suicide while being treated for anxiety and depression (01HDC14511)
Management of metastatic disease by surgical and oncology services (09HDC02227)
Delay in provision of services to patient with vascular problems (09HDC01146)
Assessment and risk evaluation of a mental health inpatient; discharge planning and systems to ensure continuity of care (09HDC01156)
Complications following laparoscopic hernia repair (09HDC01329)
Care of elderly man following fall; DHB complaint handling (09HDC01357)
Management of anticoagulation therapy (09HDC01765)
Administration of medication to mental health patient (09HDC01408)
Preoperative investigations and surgical standards for laparoscopic cholecystectomy (09HDC01505)
Provision of appropriate care to disability service provider (09HDC02149)
Naming Policy
Open Disclosure
FAQs
Publications
Resources to order
How to make an order
Posters
Leaflets
Pocket Cards
Audio Tapes
Compact Discs
Video / DVDs
Reports
Leaflets and posters for DOWNLOAD
Other publications from HDC
Articles
Other Reports
Annual Reports
Media Releases
Planning Documents
Stories about Great Care
Submissions
Disability Resources
Top of Page