The junior surgical registrar who assessed the man who came to hospital with signs of internal bleeding was not aware they needed to investigate the possibility of an aorto-enteric fistula, the commissioner said. Photo: 123RF
A man was sent home from hospital without doctors checking for a potentially fatal condition due to a communication breakdown, the Health and Disability Commissioner has found.
The man died the following day of unrelated causes.
The man, aged in his 60s, had undergone major surgery on his abdominal aorta - the main artery from the heart - two years before going to hospital in Health NZ's Southern region in 2019 with signs of internal bleeding.
In findings released on Monday, the commissioner said the junior surgical registrar who assessed him was not aware they needed to investigate the possibility of an aorto-enteric fistula (AEF) - a serious and sometimes fatal complication after that type of surgery.
Commissioner Morag McDowell said the doctor did not consult a senior vascular surgeon for advice.
Later, the doctor told other medics there was "no evidence of aortic pathology", which a gastroenterologist mistakenly took to mean the condition had been ruled out.
The gastroenterologist did not verify that against the man's medical records before discharging him, the commissioner said.
The man died at home the following day.
His son complained his father was discharged when still unwell with unidentified internal bleeding.
While the cause of death was unrelated to an AEF, the commissioner said Health NZ Southern had failed to provide services with reasonable care and skill.
"Given that an AEF is a life-threatening diagnosis that needs to be investigated urgently, there was a concerning lack of responsibility taken by anyone to ensure that this had been done," she said.
"Staff failed to communicate effectively, deferred to others, and passed on the responsibility without using critical thinking or making individual assessments."
Doctors cleared, but care process under scrutiny
McDowell said she accepted the junior surgical registrar would not have known about the possibility of an AEF.
But it was concerning he documented "no evidence of aortic pathology" - mistakenly leading others to false conclusions - without seeking advice from a vascular surgeon, she said.
Overall, McDowell found the doctor was not in breach of the Code of Health and Disability Services Consumers' Rights, but had reflected on these events and made changes to the way he documented in clinical notes.
Hearing about the case had affected the junior surgical registrar deeply, McDowell said.
"He has spent considerable time reflecting on the events. He believes that he practises very differently now," she said.
The gastroenterologist "should have confirmed, by review of the clinical record, that the appropriate investigations had been completed", McDowell said.
"I am critical of his lack of critical thinking and diligence."
He had also "reflected on how he accepts information from other providers", she said.
"I consider this to be appropriate and to serve to minimise the risk of such an event happening in the future."
Health NZ Southern had updated its registrar orientation programme following the man's death to ensure on-call surgical registrars discussed any subspecialty questions with an appropriate specialist, McDowell said.
In her recommendations, she advised sharing the findings with staff as a "learning resource to highlight the importance of critical thinking at each stage of care".
She also recommended providing ongoing refresher training on AEF and outlining the expected process for identifying and ruling it out.
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