In November 2018, the man had knee surgery at a private hospital to repair a torn meniscus (fibrocartilage found in the knee joint).
A month later he died, after he turned up twice at Auckland’s Middlemore Hospital with increased leg pain and “purpling” of the limb.
The man’s partner said despite the routine nature of the surgery, there was a “systemic failure” within the health system to identify, assess, and appropriately manage the significant risk factors which led to a pulmonary embolism (PE) caused by a deep vein thrombosis (DVT), which ultimately placed him in grave danger.
A coroner later confirmed this was the cause of the man’s death.
McDowall said, in finding fault in the hospital’s handling of the matter, it could not be said with any degree of certainty that the clinical pathway and ultimate outcome would have been any different had the patient received a more senior review at a point in the process.
“Tragically, [Mr B] suffered a recognised but low probability fatal complication,” she said.
Findings arrive five years after complaint
The complaint about the care provided to the man at Middlemore Hospital (Health New Zealand/Te Whatu Ora Counties Manukau) landed with the HDC in July, 2021.
After the man’s surgery, he was discharged days later but developed “pain and tenderness” in his right calf when standing.
He was referred for an ultrasound, which identified an extensive DVT – a blood clot which forms in a deep vein, most commonly in the legs.
He was referred to Middlemore Hospital, prescribed two blood-thinning medications and discharged.
He returned the next day to the hospital’s Emergency Department after ongoing pain and discolouration in his right calf.
The HDC noted, however, there were inconsistencies in the clinical records about which leg was affected.
‘Mild purplish hue’
Upon arrival at ED, a senior emergency medicine specialist did an initial assessment, documented the man’s history of knee surgery, the diagnosis of DVT, and his previous visit to hospital.
She also noted the man commented he was becoming more immobile and his leg pain meant he could not put weight on it.
In the shower, he noticed his entire leg was purple, but he did not have any shortness of breath or chest pain.
He was admitted to the general medicine ward and reviewed by a junior doctor, working under the broader supervision of a senior medical officer and under the direct supervision of a registrar.
The junior doctor conducted a physical examination and documented that the patient’s observations were stable, that his leg was tender along the posterior length of the calf, and that he was “unable to fully weight bear” due to calf pain and throbbing when his leg was not elevated.
The doctor also noted that when the man was standing, he developed a “mild purplish hue” in his leg from mid-thigh down.
His clinical impression was “extensive lower limb DVT” with symptoms where the blood flow in the man’s lower legs had slowed or stagnated.
In a later statement to the coroner, the junior doctor said that after assessing the man, he discussed his care with two medical registrars and told them he considered that the man was on the appropriate medical therapy for DVT.
McDowall said the junior doctor claimed the registrars agreed with his clinical assessment, but there was no documentation of those discussions.
A departmental adverse event review found the junior doctor had discussed the man’s care with two registrars, one of whom considered he could have been clearer in his own communication with the junior doctor.
The man was subsequently discharged and sent home with pain relief medication, instructions to continue with the DVT treatment and information about PE symptoms.
He collapsed at home the next day, and went into cardiac arrest while in the ambulance headed to Middlemore.
Despite resuscitation efforts en route, he later died.
Health and Disability Commissioner Morag McDowell expressed her sympathies to the man’s family and friends for their loss in such tragic and unexpected circumstances. Photo / HDC
A CT scan showed he had experienced a subarachnoid haemorrhage – a type of stroke, but the coroner confirmed his death was the result of the PE, secondary to DVT.
Health NZ’s Adverse Event Review found that the care provided to the man was of an appropriate standard overall, but the junior doctor should not have discharged him without being seen by a registrar.
Second presentation focus of HDC investigation
McDowall said the key issue for the HDC’s investigation related to the man’s second presentation to Middlemore Hospital on December 15, 2018, and whether he was provided services of an appropriate standard and skill.
She noted the process for obtaining senior oversight did not occur as it should have, and was also concerned that important conversations between the junior doctor and registrars were not documented.
McDowall said the failings should be attributed to the provider, rather than the individuals concerned and therefore found Health NZ in breach of the Code of Health and Disability Services Consumers’ Rights for failing to provide services to the man with reasonable care and skill.
Health NZ had since made several changes to address the concerns identified.
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.