• Southland Hospital staff lost an envelope with vital patient notes when an elderly man was taken to hospital.
• Health and Disability Commissioner Deborah James said the hospital’s care of the man, who died a week later, was “unacceptable”.
• A doctor who failed to order a CT scan said she was “very overwhelmed” on the night the man was brought in.

An elderly man died from a brain hemorrhage a week after visiting an Emergency Department, where he was kept sitting in a wheelchair for hours, staff lost vital patient notes, and a “very overwhelmed” doctor failed to order him a scan.

The Health and Disability Commissioner has called Southland Hospital’s care of the man “unacceptable” and said it should provide a written apology for its breach of his patient rights.

The man’s son said it appeared that the hospital had placed “budgetary concerns ahead of patient care”.

The man, named only as Mr A in the report of Deputy Health and Disability Commissioner Deborah James, was in his eighties when he suffered a fall at his care home in 2020. He had a 10cm head wound.

The ambulance staff who took him to the Emergency Department (ED) took with them a yellow envelope provided by the care home, containing the man’s medication chart and other notes, in line with a long-standing practice.

The yellow envelope was lost at the hospital.

Ambulance staff said they handed it to a person behind a glass screen in the ED reception. The two receptionists on shift said they had no recollection of being given it.

The ED registrar, named only as Dr C, said Mr A was placed in a wheelchair in the waiting room and allocated a triage category which meant he should have been seen within 60 minutes.

Dr C said she moved Mr A to a “fast-track” area of ED about 2am, when he had been in ED for four hours, and a registered nurse took his initial observations at 6.30am.

Patient did not know which city he was in

At that time his “early warning score” indicated no concern, but notes also mentioned that Mr A could not give his full birthdate or say which city he was in.

At 6.57am, Dr C noted that Mr A had been waiting a long time to be seen, smelt strongly of urine and had a full catheter bag.

He had a normal pulse and normal sensation and power to his limbs, and normal arm co-ordination, but he did not understand assessment instructions and he was “slow and shaky”.

Dr C was unaware that Mr A was taking warfarin - a blood-thinning medication used to prevent blood clots. This information had been in the yellow envelope, which she did not see.

Dr C said because she was unaware that Mr A was on anticoagulants, she did not order a head CT scan.

She told the commissioner that had she been aware he was on warfarin, her “usual practice would be to perform a CT of his brain prior to discharge”.

After Mr A’s head wound was sutured, he was kept in ED for observation, but still in a wheelchair due to a lack of beds.

At the 8am handover, Dr C told a consultant that Mr A’s wound had been sutured and that he appeared stable after his night in ED.

The consultant asked if Mr A was on anticoagulants and Dr C said she believed that he was not.

Mr A was discharged back to his care home at 10am.

The care home referred him to his general practitioner the next day because he was unwell with increased confusion and shaking.

Patient’s health declines

On Day 8, there was a further decline in his health. He could not open his eyes, talk or move his limbs.

He was sent back to Southland Hospital where an urgent CT scan showed he had suffered an intracranial hemorrhage and clinical staff discovered he was on warfarin.

He was admitted to the hospital where, despite warfarin reversal treatment, he died.

Dr C told the HDC that doctors working in the ED overnight were discouraged from requesting CT scans unless they were immediately needed, due to factors including having to call in the radiographers from home, which would impact the service the following day.

“I accept ... that given [Mr A’s] level of functioning and situation that a CT head scan was indicated, and I regret and am sincerely sorry for not arranging this prior to [Mr A’s] discharge,” Dr C said.

“This case and the resulting reflections and learnings continue to, and will always, inform my practice,” said Dr C, who has since moved to another location.

The man was taken to Southland Hosptial. Photo / Allison Beckham

Health New Zealand, the agency which oversees the hospital, said that at the time of the events, it ran an “on-call” service for patients requiring urgent CT scans at night, and clinicians were asked to request scans only for those patients whose immediate management depended on the results.

This was to ensure that the day-time running of the service was not “unduly affected”.

The man’s son said it seemed resourcing at the hospital was thin, but limiting CT scans due to staff shortages “appears to place budgetary concerns ahead of patient care and this is disappointing”.

Dr C said she recalled feeling “very overwhelmed” by the number of patients waiting to be seen, and the lack of spaces to see them, on the night Mr A was brought in.

The HDC found that Dr C had breached Mr A’s patient rights, and she agreed to provide a written apology to his family.

Deputy Commissioner James also found that Health NZ Southern had breached Mr A’s patient rights.

She said that he was an elderly man who had been forced to wait for four hours in the ED waiting area “when clearly he was distressed” and a further two and a half hours in the fast-track area before he was seen for initial observations.

This was despite a triage category which stated he should have been seen within the hour.

“This is unacceptable care of a patient with a head injury, irrespective of whether it was known at that time that he was on warfarin,” James said.

Health NZ Southern has been approached for comment.

Southland Hospital told the commissioner that it had conducted an adverse event review, and implemented the recommendations that came out of it.

These included reviewing the protocols around the use of the “yellow envelope”, and education about where to source information about warfarin use in the absence of it being supplied.

Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.