The Health and Disability Commissioner has recommended that a District Health Board carry out an audit and implement new systems after a patient died following surgery.

The patient received brain surgery at a private hospital. Due to complications following the surgery, the patient was transferred to the public hospital for urgent care.

The private surgeon gave brief instructions for treatment to the public hospital. The senior doctor at the hospital informed a junior doctor that the patient was to be administered an anticoagulant (to stop blood clotting) and to get a head scan.

The scan was intended to be carried out initially, but, due to the priority of the request incorrectly having been made as “semi-urgent” instead of “urgent”, the patient was started on the medicine first.

The junior doctor chose the wrong treatment protocol for the medicine and started the patient on a dose that was far higher than was recommended for a patient with a high bleeding risk.

Despite the patient later complaining of a headache, he still did not receive a head scan for two hours.

When the scan was performed, it showed a major bleed on the patient’s brain. Despite emergency surgery, he died.

The Commissioner held that the lack of awareness about the appropriate drug chart for prescription protocols by senior doctors meant that they were “not in a good position to be guiding junior doctors”. Additionally, the incorrect urgency status for a scan, and significant delay despite the patient complaining of a headache, added to the patient being put at risk of a poor outcome.

The Commissioner held that the DHB breached the patient’s right to have services provided with reasonable care and skill.

The Commissioner recommended that the DHB provide a report of the reviews carried out into making requests for scans and how specialist support is provided, conduct an audit of junior doctors on prescribing that particular drug and when to seek assistance, and an update on the development of a pathway for treating complex patients.

It is important that proper supervision is provided to junior doctors, and that all instructions are communicated in a clear and detailed way. Failure to do so may result in poor health outcomes of patients in their care.

If there are concerns about the care provided by a doctor, it is wise to speak with a professional experienced in the area.

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Alan Knowsley