A series of failures by the Northland District Health Board led to an unacceptable delay in the treatment of a man who was admitted to hospital but died after his condition deteriorated, a report by the Health and Disability Commissioner says.
The 69-year-old man, referred to in the report as Mr B, was admitted to Whangarei Hospital's emergency department over a weekend in mid-2009 with suspected coronary problems.
That same day, he was admitted to a medical ward after his vomit was found to be tinged with blood.
Mr B was seen the following day by a consultant physician, who confirmed he was suffering an upper gastrointestinal bleed, and he was referred for a gastroscopy.
However, Mr B's condition deteriorated with further vomiting, prompting the gastroscopy to be deferred.
Three days after his initial admission to hospital, Mr B vomited more blood, collapsed and died.
In the report, Health and Disability Commissioner Anthony Hill says the man's deterioration was not fully recognised by hospital staff, who gave insufficient consideration to other diagnoses once the initial diagnosis was made.
"The care provided by the DHB was suboptimal, highlighted systems issues, and was a moderately severe departure from expected standards," Mr Hill said.
The failures of the District Health Board were found to be a breach of the patient's right to have services provided with care and skill.
Mr Hill has made a series of recommendations to the Northland DHB to improve its processes following Mr B's death.
He has requested that the DHB report back on its progress.
NZN