Opportunities to "rescue" an elderly woman with Crohn's disease before she died were not acted on, according to findings from the health watchdog today.
Health and Disability Commissioner Anthony Hill faults the Waitemata District Health Board over the case in 2015.
He said the woman was admitted to hospital because of a relapse of her Crohn's disease. While there she suffered from nine episodes of rectal bleeding, losing 50 to 100ml of blood each time. "Attempts to transfuse red blood cells were made, but Mrs B's anaphylactic reactions prevented adequate replacement of her blood loss," Mr Hill said.
Later on, junior doctors spoke with a radiologist at another DHB about the possibility of stopping the bleeding by blocking a blood vessel - a procedure known as embolisation.
They both understood from the discussion that the woman was not suitable for this procedure because of her Crohn's condition.
The interventional radiologist herself, however, said later that she had not excluded embolisation, but suggested that the surgical registrar assess the woman (known as Mrs B) and discuss "all possible treatment strategies" with senior consultants.
Instead, it was decided to continue with conservative measures and proceed with surgery if Mrs B became "more unwell". About an hour later, however, she became increasingly drowsy and an emergency bell was activated at 3.20am one day.
Forty minutes later she had emergency surgery to control her bleeding. After this she was transferred to intensive care where she was later given palliative care and about a week later she died.
Mr Hill was critical of the care given by a number of Waitemata DHB staff. He said: "There was a preventable 48-hour delay in carrying out a colonoscopy, and an inadequate response to Mrs B's ongoing bleeding and transfusion reactions. Junior staff failed to escalate her condition to a consultant level, she was not admitted to ICU [intensive care] following the first emergency call, and poor decision-making led to delayed surgical intervention."
Mr Hill has asked the DHB to report back to him on a recommendation from an expert adviser that there should be a policy that "all patients with gastrointestinal bleeding are made know to surgical services".
He also wants the DHB to carry out a random audit of documentation within the general medicine ward to ensure that treatment plans and discussions with other speciality areas are documented adequately.
In addition, he wants the DHB to provide a further update on progress about recommendations from its serious adverse event review, and to apologise to Mrs B's family.