A hospital has been ordered to conduct an audit of its neurology referrals after a man who was admitted with weakness and twitching on one side was not seen by a neurologist for four days.
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Health and Disability Commissioner Anthony Hill said a scan suggested the patient had suffered a brain injury and it was recommended that a neurological opinion be sought.
The man arrived at the emergency department with sudden onset of left-sided weakness and twitching, and reported a week-long history of dizziness upon standing.
However the man was mistakenly sent to outpatient referrals and despite being seen by several doctors, it was not until four days after admission that a medical registrar discovered he had not been seen by a neurologist.
The registrar then arranged for that to happen.
Mr Hill said there was a pattern of poor care in the case and he was particularly concerned about lapses in communication within the general medical team.
He also expressed concern about the lack of safeguards in place to identify issues in the neurology referral process.
The commissioner also recommended the DHB provide a formal written apology to the man for the deficiencies in his care.
