A CT scan identified a suspected saccular aneurysm which was confirmed by further investigation, but no follow-up with a specialist happened. Photo \/ 123rf<\/p>\n
Three months later, the 66-year-old collapsed while playing golf, with symptoms of vomiting, a low heart rate, and difficulty breathing. <\/p>\n
She was flown by rescue helicopter to a tertiary hospital, where it was confirmed her aneurysm had ruptured, causing a severe brain bleed. <\/p>\n
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 <\/a>said in a report released today. <\/p>\n Health NZ breached care code<\/p>\n 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\u2019 Rights.<\/p>\n She said while a doctor made a verbal referral for the woman\u2019s follow-up care, it remained the responsibility of the regional hospital<\/a> staff to make a formal written referral to the tertiary hospital neurosurgery department, which should have happened. <\/p>\n \u201cWritten referrals support safe practice for several reasons,\u201d Cooper said.<\/p>\n She offered her heartfelt condolences to the woman\u2019s family for the tragic outcome.<\/p>\n First signs of trouble<\/p>\n Just before Christmas, 2021, the woman arrived at her rural hospital\u2019s emergency department with symptoms indicating she had experienced a transient ischaemic attack (TIA) – a \u201cmini-stroke\u201d with temporary symptoms.<\/p>\n She was transferred to a secondary-level regional hospital, where a scan was done to evaluate the suspected TIA. <\/p>\n The CT scan showed no evidence of a new stroke, but it identified a suspected saccular aneurysm.<\/p>\n 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<\/a>. <\/p>\n The registrar called the doctor at the regional hospital and recommended that a CT angiogram be performed. <\/p>\n The doctor recorded in clinical notes that the registrar also advised the woman\u2019s case would be discussed by the neurosurgical team, and she would be contacted regarding follow-up care<\/a>.<\/p>\n 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.<\/p>\n On the same day, the woman was discharged with three weeks\u2019 of dual-antiplatelet (anti-coagulation) medication. <\/p>\n Cooper said her discharge summary stated that her case would be discussed by the tertiary hospital neurosurgery department, and that she would \u201creceive a letter or phone call from neurosurgery for outpatient clinic follow-up\u201d.<\/p>\n No call, no letter<\/p>\n 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.<\/p>\nDeputy 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.<\/p>\n