A 62-year-old man died at home in his bed 17-and-a-half hours after being sent home from a hospital emergency department.
In a report released today, Health and Disability Commissioner Anthony Hill said an unnamed registered nurse and senior emergency department (ED) doctor failed to provide good care.
He said that after feeling unwell for days, the man went to the ED in 2014 with an abnormal heart rate, temperature and breathing. The nurse recorded his blood pressure and oxygen saturation levels over three hours, but not his pulse, breathing or temperature.
Mr Hill said the man's oxygen levels were low enough to indicate severe hypoxia, but no action was taken over that issue.
He added that the nurse failed to tell the senior ED doctor about the hypoxia result, which with the other readings, indicated severe sepsis. That meant that admission to hospital, and potentially intensive care, was needed.
Instead, the doctor ordered the urgent administration of IV fluids, diagnosed pneumonia and discharged the man home. The man's cousin, who came to collect him from hospital, told Mr Hill that his cousin was sitting in the waiting room and did not look happy.
He was found dead in his bed next morning and a coroner reported that the cause of death was complications of flu with widespread heart muscle scarring as a contributing factor.
The nurse said she could not recall the details and regretted that her documentation of her actions appeared incomplete.
Mr Hill said she breached patient rights, and needed to have someone audit her documentation in the ED over a month. She also needed further training in patient monitoring.
The doctor, Dr D, complained to Mr Hill that it was a particularly busy shift with "multiple complex presentations". He added he was the sole senior doctor and looking after seven other patients while also overseeing the patients of another doctor.
A doctor known only as Dr I said it was difficult for doctors to see nurses' notes and lab notes were also hard to monitor because computers logged off after a few minutes and were slow to process.
Dr I added that there was no integrated electronic medical system.
He told Mr Hill that the case "has hallmarks of a hurried decision, a discharge where the attending doctor lacked time to marshal all the data, think out the case and reflect on the entire picture."
He concluded however that those matters did not excuse a medical mistake by Dr D.
For its part, the DHB acknowledged it did not have an integrated electronic medical system, saying that was a "utopic situation that all DHBs in the country are trying to achieve". It accepted that improvements were needed in the ED but said it was safe and the need for improvement was irrelevant to what happened.
Mr Hill said Dr D should have reviewed all the test results about the man before discharging him. The failure to do this breached patient rights, and the Medical Council had decided separately that he would need to undergo a performance assessment.
He said the unnamed DHB was not liable for the failures as the ED was not too busy or under-staffed at the time.