A woman discharged from a hospital twice in 24 hours with pain and swelling in her leg had to undergo major surgery for deep vein thrombosis when she returned a third time.

The woman was misdiagnosed with sciatica during her initial visits to Auckland Hospital in April 2016 until “unbearable pain” resulted in her being rushed back in an ambulance only hours later.

Further assessment discovered a retroperitoneal bleed and deep vein thrombosis leading to a major procedure for the woman and time in the Cardiovascular Intensive Care Unit and lengthy rehabilitation.

Following her bungled care, the woman lodged a complaint with the Health and Disability Commissioner (HDC) for investigation.

A preliminary assessment of the complaint was undertaken and then closed in 2018. But following review by the Ombudsman and consideration of additional information, the HDC reopened the complaint in 2021 and commenced an investigation the same year.

The HDC took a “fresh eyes” approach to the case, with the information and evidence considered by a new investigator and a new commissioner, Morag McDowell said in her findings, released on Monday.

In her decision, McDowell ruled the Auckland District Health Board, now Te Whatu Ora Te Toka Tumai, and a vascular registrar breached the Code of Health and Disability Services Consumer’s Rights (the Code) in relation to the woman’s care.

Health and Disability Commissioner Morag McDowell investigated the woman's complaint. Photo / Dean Purcell

The commissioner has made a number of recommendations including that Te Whatu Ora and the two registrars who treated the woman provide her with written apologies.

McDowell said in her decision the patient was experiencing pain on April 26, 2016, following a privately performed sclerotherapy procedure she had had the previous month to treat a varicose vein.

The unnamed woman returned to the doctor at the vein clinic, who performed the procedure and is referred to as Dr D in the decision.

An ultrasound scan was taken of the woman’s left leg and Dr D referred her to a vascular registrar at Auckland Hospital.

In Dr D’s referral letter, the woman’s leg was described as being swollen from her ankle to her groin, cooler in temperature, red in colour, and that she had been in pain for two days with nausea and vomiting.

The woman went to the hospital that same day and was admitted to the Assessment and Planning Unit (APU) before seeing the vascular registrar, Dr C.

A number of tests were undertaken and Dr C diagnosed sciatica caused by recent heavy lifting.

She was discharged with a plan to attend outpatient physiotherapy and left the hospital around 10pm.

But roughly 20 minutes later, as she was walking to her car on the hospital’s grounds, the woman “collapsed” and began “violently vomiting”.

Two nurses heading to work came to her aid and she was readmitted to the APU. The triage note recorded “failed discharge, feeling faint, vomiting”.

Dr C assessed the woman again and noted there were no changes to her vitals nor her examination findings.

Her family’s recollection of the second review is that Dr C had another “quick look at her leg” by lifting the sheet.

Dr C later told the HDC he had advised colleagues the woman should be admitted for observation and referred her to the medical team for assessment. He had planned to discuss the case with the consultant in the morning.

But he made no clinical notes in relation to this review, meaning his referral and instructions to the medical team went undocumented.

The woman was seen by Dr B, a general medicine registrar, a short time later. He found she was comfortable with oral pain medication and was mobilising independently, and therefore she did not need to be admitted to hospital.

He saw no evidence to change Dr C’s diagnosis of sciatica and she was discharged around 12.30am.

But around 3am, the woman began suffering “unbearable” pain and an ambulance was called.

She was taken to the hospital’s Emergency Department and a CT scan was performed and reviewed by the on-call vascular surgeon.

The images showed she had a retroperitoneal haematoma and a suspected clot in the iliac veins.

In McDowell’s decision, the commissioner found at the time of the second hospital visit, given the ongoing severe pain without a clear diagnosis, an ultrasound or CT scan should have been arranged.

She found the vascular registrar in breach of Right 4(1) of the Code, that every consumer has the right to services of reasonable care and skill in relation to failing to undertake further investigation when the woman returned to hospital the second time.

McDowell also found Te Whatu Ora breached the Code for failing to provide the woman with care of an appropriate standard, including that documentation of the medical reviews from her first two presentations were inconsistently recorded.

“...and the failure to have set out clearly its expectations for referrals between specialties, which did not support a safe clinical journey for the woman.”

She also criticised documentation by the vascular registrar and a general medicine registrar.

Among her recommendations, McDowell advised Te Whatu Ora to use the woman’s case as the basis for training its new registrars in medical and vascular services, and that Te Whatu Ora confirm its current orientation included clear guidance about who is to document internal referrals.