The health watchdog says hospital staff missed crucial opportunities to look at a woman’s medical history after she died within a week of being sent home following ankle surgery.

The decision, released by the Health and Disability Commission today, notes how the woman had a history of deep vein thrombosis which hospital staff failed to identify and was ultimately the cause of her death.

The woman was in her 60s when she was admitted to an unnamed hospital with a broken ankle for which she underwent surgery.

She was released from hospital but five days later she died of a pulmonary embolism - which is where a blood clot, usually formed in the leg, travels to the lungs and becomes lodged in the smaller arteries located there.

The woman, who was identified only as Ms A in the report, had a history of venous thromboembolism and had developed deep vein thrombosis (DVT) after having achilles tendon surgery and again after a long car journey.

When she turned up at the emergency department in 2021 after a fall she filled out a questionnaire noting her history with DVT.

Five days after being discharged from hospital an ambulance was called for the woman after her daughter reported that she had trouble breathing. Ambulance staff administered CPR but were unable to save the woman.

The cause of death was identified during a post-mortem examination as a deep vein thrombosis in the woman’s left leg.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell said the hospital’s assessment procedures for identifying venous thromboembolism (VTE) were inadequate and that the woman’s specific risk factors were not considered by staff appropriately.

“There were missed opportunities for staff to assess Ms A’s condition critically and put in place a management plan to address the risks appropriately… I consider this to be a service delivery failure for which, ultimately, Te Whatu Ora is responsible,” Caldwell said.

She also recommended the organisation formally apologise to the woman’s family for the failings identified and said it should review its policy on assessing and managing VTE risk, and its recommended preventative measures on admission and discharge.

Caldwell also required Te Whatu Ora to provide training to all the staff who were involved in Ms A’s treatment and complete an audit of at least 15 patients to make sure its new policies were being complied with.

In response, Te What Ora said the woman’s questionnaire did record her history of DVT but there was no evidence that any of the staff at the hospital noted it, or passed on the information.

“Ms A’s history of DVTs was highly relevant to guide the clinical decision-making. I am critical that the surgical staff were not aware of this information and did not specifically ask Ms A about her history of DVTs prior to the surgery,” Caldwell said in response.

“In addition to her history of DVTs, Ms A had other factors that suggested that she was at risk of developing a DVT. Her BMI was elevated (obese) and she had high blood pressure. However, it appears that these factors were also overlooked.”

Te Whatu Ora also acknowledged that if the woman had been assessed as being at risk of DVT then staff could have altered the kind of medication and after care she was prescribed which may have “altered her outcome”.

Jeremy Wilkinson is an Open Justice reporter based in Manawatū covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.