A man who had been recovering well at Waikato Hospital died within four days following a botched transfer to a rehabilitation facility.
Health and Disability Commissioner Anthony Hill said in a report today that the Waikato District Health Board and ABI Rehabilitation New Zealand Limited were both at fault in the case.
Mr Hill said the 58-year-old man had sustained multiple injuries in an accident and required time in intensive care.
He made good progress, however, on medications including a blood-thinner known as Clexane, which reduces the risk of deep vein thrombosis, and pain relief.
It was decided to move him to rehabilitation closer to his home, but flight arrangements meant the move did not occur until late on a Friday night.
Three syringes of the Clexane medication were given to the patient's wife, Mrs A, to be given to him over the next several days at the rehabilitation facility, but confusion and a lack of documentation sent with Mr A meant the Clexane was never given to Mr A. He also did not receive a medical review or assessment at the facility when he was admitted.
Mr Hill said the public hospital discharge summary did not refer to discharge medications or the ongoing use of Clexame or anti DVT-regime.
Confusion and incorrect information meant that for two days Mr A had inadequate pain relief, and he received no Clexane at all at the facility.
He died with an autopsy indicating death was due to a pulmonary embolus following deep-vein thrombosis.
Mr Hill said Mr A's right to co-ordination and continuity of care was compromised by the DHB. He said for its part ABI Rehabilitation had two policies regarding admission, which resulted in very unclear direction to staff about the admission requirements and timing of a medical review.
"It is unreasonable for a trauma patient to wait more than 72 hours to be assessed for admission by medical staff in a new facility. In my view this was a wholly unacceptable situation," said Mr Hill.
Mr Hill said he had recommended the DHB carry out a random audit of discharge summaries from its Trauma Service to ensure improvements including a checklist were being followed.
"I want to see not only that policies are in place but they are [also] being effectively complied with. So what I'm looking for is the reassurance from the DHB that in fact change has occurred and that it is being reliably complied with."
The DHB's executive director of the Waikato Hospital Service, Brett Paradine, said it had taken responsibility and apologised unreservedly for the errors.
He said the DHB has had the findings from Mr Hill since December and had already begun making changes, including reviewing its pre-transfer checklist for major trauma patients being transferred to other facilities.
"I think the key thing is to make sure that the discharge preparation is done well in a way that all members of the team understand and is communicated to the receiving facility - I think that's where this has clearly fallen down," said Mr Paradine.
ABI New Zealand did not respond to a request for comment.