A CT scan identified a suspected saccular aneurysm which was confirmed by further investigation, but no follow-up with a specialist happened. Photo / 123rf
Three months later, the 66-year-old collapsed while playing golf, with symptoms of vomiting, a low heart rate, and difficulty breathing.
She was flown by rescue helicopter to a tertiary hospital, where it was confirmed her aneurysm had ruptured, causing a severe brain bleed.
As she showed no signs of neurological recovery, her family agreed that the focus of treatment should be changed to palliative care only, and she died shortly afterwards, the Health & Disability Commissioner said in a report released today.
Health NZ breached care code
Deputy commissioner Carolyn Cooper said Health NZ did not provide an appropriate standard of care and was therefore in breach of a section of the Code of Health and Disability Services Consumers’ Rights.
She said while a doctor made a verbal referral for the woman’s follow-up care, it remained the responsibility of the regional hospital staff to make a formal written referral to the tertiary hospital neurosurgery department, which should have happened.
“Written referrals support safe practice for several reasons,” Cooper said.
She offered her heartfelt condolences to the woman’s family for the tragic outcome.
First signs of trouble
Just before Christmas, 2021, the woman arrived at her rural hospital’s emergency department with symptoms indicating she had experienced a transient ischaemic attack (TIA) – a “mini-stroke” with temporary symptoms.
She was transferred to a secondary-level regional hospital, where a scan was done to evaluate the suspected TIA.
The CT scan showed no evidence of a new stroke, but it identified a suspected saccular aneurysm.
A doctor sought advice from a tertiary hospital neurosurgery registrar, who confirmed the woman should continue to receive treatment to prevent blood clots from forming, to reduce the risk of a subsequent stroke.
The registrar called the doctor at the regional hospital and recommended that a CT angiogram be performed.
The doctor recorded in clinical notes that the registrar also advised the woman’s case would be discussed by the neurosurgical team, and she would be contacted regarding follow-up care.
The CT angiogram confirmed the diagnosis of a saccular aneurysm. However, it appeared the result was not communicated to the tertiary hospital neurology department, Cooper said.
On the same day, the woman was discharged with three weeks’ of dual-antiplatelet (anti-coagulation) medication.
Deputy health and disability commissioner Carolyn Cooper was critical that no written referral had been made, which meant the woman did not receive the neurosurgical follow-up care she needed.
Cooper said her discharge summary stated that her case would be discussed by the tertiary hospital neurosurgery department, and that she would “receive a letter or phone call from neurosurgery for outpatient clinic follow-up”.
No call, no letter
Neither a letter nor call arrived, and the woman and her husband found, after following up themselves in February 2022, no appointment had been made.
Health NZ told the HDC there was an assumption the woman would be seen by the tertiary hospital’s neurosurgery department, based on the regional hospital doctor’s phone discussion with the registrar.
However, Health NZ was unable to find any evidence that a written referral was sent to the tertiary hospital neurosurgery department.
Cooper said the registrar had since left the country and was unable to be contacted.
Apology from Health NZ
Health NZ later acknowledged its referral process was inadequate and had apologised.
It also said it did not have an electronic referral management system for referrals to the tertiary hospital, which told the HDC it did not have any record of the discussions between the registrar and the doctor, and that no referral was received.
Cooper was concerned over the inadequate staff support systems at the regional hospital, and she was critical that no written referral had been made, which meant the woman did not receive the neurosurgical follow-up care she needed.
She recommended Health NZ establish a protocol to ensure that, in addition to any verbal referrals to other services, written referrals were also completed.
Cooper also recommended it consider putting in place an electronic system for referrals to the tertiary hospital specialist services.
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.