The Health & Disability Commissioner has found that Capital Coast DHB breached the Patient Code of Rights by failing to adequately treat a patient after she was admitted to hospital on two occasions following multiple collapses and vomiting.

On the first occasion the admitting doctor referred the patient to the Consultant.  The Consultant felt that the patient’s symptoms were not serious and discharged her without adequate follow up. 

When she was readmitted following further collapses the admitting doctor tried to refer the patient to the medical team again, but the patient refused to be referred to the medical team and then after agreeing to be referred to the team, self-discharged herself from the hospital against advice, before seeing the team. 

The patient was later found to be suffering from a brain tumour. 

The Consultant who saw the patient on the first admission was found not to have offered the right investigations and in particular a CT scan or a referral for an urgent neurological review and that he discharged her without adequate follow up arrangements. 

In relation to the second admission, although the patient self-discharged, the hospital failed to make the proper referrals and failed to adequately record the decision making processes in the notes.

Both the Consultant and the hospital are to provide written apologies to the patient.  The hospital was also to examine its procedures in relation to urgent CT head scans, adequacy of its note keeping and the referral to Consultants when patients re-present to the hospital or where they wish to leave the hospital contrary to medical advice.

Alan Knowsley
Medical Lawyer