Health New Zealand Southern has been asked to apologise for the care of a man who died in Dunedin Hospital after a failure to treat a sudden and severe decrease in blood flow to his leg.
In a Health and Disability Commission decision released publicly on Monday, HNZ Southern has been asked to provide a written apology to the family within a month, and provide the commission with “ongoing quality improvement initiatives” by January 2027.
The decision’s summary said a man presented to Dunedin Hospital on March 18, 2021, with an elbow injury after a fall at home.
The man had an extensive medical history, including vascular surgery, cardiac surgery, diabetes, and peripheral vascular disease (PVD).
The man underwent initial surgery on his elbow and remained in hospital on the orthopaedic ward to await further surgery.
On March 19, 2021, the orthopaedic house officer (HO), reviewed Mr A for concerns of left leg numbness and pain in the sole of the left foot.
After examination and discussion with the man, the doctor noted that he was known to the vascular service with a history of PVD and peripheral neuropathy (damage to peripheral nerves) and that he reported that the leg numbness and foot pain were longstanding and ‘basically at baseline’, although the pain was ‘slightly worse since [the] fall].’
The doctor concluded, ‘this is likely a chronic issue unlikely related to [the] fall.’
The man was then seen by an orthopaedic senior medical officer (SMO), with the HO in attendance.
A physiotherapist had alerted the doctor that the man was unable to stand.
The SMO recalled that, after examining the man’s legs, he felt that the left leg was acutely ischaemic (restriction in blood supply to tissues) and required review by the vascular service. However, the HO did not document this suspicion.
The documented plan, as related to the left leg, was for ‘vascular consult about PVD.’
The HDC considered this a clear “communication breakdown between staff”.
There was also “no initial basic vascular assessment”.
“Therefore, no baseline measures of circulation, sensation, pain, or movement by which progressive changes could be measured were available.”
The directives were also criticised.
“[The doctor’s] documentation on March 19, 2021 stating that the vascular team would only conduct a review if the man deteriorated was subsequently interpreted as suggesting that the team was unwilling to seethe man and became a ‘directive’ that was not challenged over the next three days.
"The man’s leg issue was assumed to be the continuation of a chronic condition rather than an acute-on-chronic event (ie, the abnormal was normalised).
"As the doctor did not document the information provided to the vascular registrar with the verbal referral, the weekend team had no reference of the clinical picture relayed at the time of referral, and, therefore, the basis on which it had been decided that the issues were not new or acute.”
The man’s condition escalated over the public holiday weekend of March 20 to 22, 2021.
On March 23, 2021, during the orthopaedic ward round, the man had no movement or sensation in his left leg.
A vascular review was arranged, and Mr A was diagnosed with ALI, requiring amputation of his left leg. Mr A underwent surgery for an above-knee amputation that afternoon. After surgery, he experienced further complications and died in hospital a short time later.
“Under Right 4(1) of the Code, Health NZ had a duty to ensure that services were provided to [the man] with reasonable care and skill,” the HDC’s decision said
“Having reviewed all the available information, I consider that this did not occur. It is unacceptable that the man was not reviewed by the vascular service until four days after the doctor identified that his leg appeared acutely ischaemic.
“Although I consider that the individual staff carry some responsibility, in my view, Health NZ is ultimately responsible for this at a service level.”