A much-loved husband and father died after he was sent home from hospital without the oxygen therapy he needed to survive.

Now, the Health and Disability Commissioner has found the man’s rights were breached when the Waitematā District Health Board failed in its discharge planning, including that it hadn’t assessed his need for home oxygen therapy.

The HDC found after an investigation prompted by a complaint from the man’s daughter and his wife that there was no formal assessment of the man’s need for home oxygen before he was discharged because of a misunderstanding about his oxygen availability at home.

Deputy Health and Disability Commissioner Carolyn Cooper said in a decision released today, that the investigation into what happened identified four key areas where the care provided “fell short of the expected standards”.

She said it was clear that there had been a breakdown in communication or understanding between the medical staff and nursing staff plus that of the man and his family that resulted in him receiving care that was not up to standard.

Deputy Health and Disability Commissioner Carolyn Cooper.

The Waitematā DHB said in a statement to NZME that it wanted to take the opportunity to recognise the death of the patient in 2020 and the deep impact it had had on his whānau and friends.

Chief Medical Officer Jonathan Christiansen said the DHB fully accepted the findings and wanted to reassure the public that it took its obligations very seriously.

The man, aged in his 70s, was admitted to North Shore Hospital in 2020 with symptoms of light-headedness, chest pain, and shortness of breath.

He was stabilised in the emergency department and admitted to a medical ward where he remained for 10 days and was discharged without home oxygen.

He became increasingly short of breath overnight and returned to hospital the next day and died the following day after resuscitation attempts were unsuccessful.

The investigation revealed “significant issues” in discharge planning, in particular, the assessment of his need for home oxygen therapy.

An extensive medical history

Cooper’s decision centred on the care the man received while at the hospital for treatment of serious health conditions, including ischemic heart disease, pulmonary hypertension and chronic obstructive pulmonary disease.

In his report to the Coroner, the man’s GP said he had “quite an extensive medical history” for which he was on long-term medication.

Further health complications led the doctor to say at one stage that the man may have been a candidate for portable oxygen.

His wife, “desperate for anything to help him, bought him a “natural ozone concentrator”, which he used daily when short of breath, around six months before his death.

Neither the DHB nor the man’s doctor were consulted about the purchase.

The ED admission summary noted that his wife used “home O2 intermittently”, and a consultant physician said in a report to the coroner that she reported having supplemental oxygen at home which he was using several times a day when he felt short of breath.

However, the complainants said he did not have prescribed oxygen at home and was never formally assessed for it.

Health NZ said that a cardiology registrar recalled making it clear to the man that “his medical issues were severe and not reversible” and that management aimed to minimise his symptoms and optimise his function.

Clinical notes showed that he was keen to go home before the weekend, and became distressed when told it would be best if he stayed a few more days, to be certain he was stable on the medication regime.

The man said he wanted to go home as it “may be his last”, so a compromise was reached that if his vital signs were stable he could go home.

The man’s wife and daughter said on the day he was discharged his level of activity was “significantly below normal”.

He was re-admitted the following day by ambulance in a serious condition.

Clinical notes showed he suffered a cardiac arrest that evening and that his daughter objected to an earlier “not for resuscitation notice”.

His daughter was “distressed at the rapid turn of events and wanted CPR to commence”.

CPR was performed and eventually stopped.

Cooper sympathised with the daughter’s distress which had factored into Health NZ’s decision-making surrounding CPR, but raised concerns it had not followed its resuscitation policy in that CPR was performed, despite it being deemed medically inappropriate.

“I consider that when a clinician has determined that resuscitation is not medically appropriate, it should not be performed, and the views of family members are not binding,” she said.

The HDC has made several recommendations including putting in place a formal assessment process for home oxygen needs before discharge, reviewing and updating discharge policies to ensure comprehensive planning and clear communication, and providing education and training for staff on the importance of critical thinking during discharge planning.

Christiansen told NZME that the Waitematā DHB acknowledged the recommendations, and was working towards implementing them.

“As always, we encourage patients and whānau to talk to us directly if they have questions about their or their loved one’s care, or to contact the Health and Disability Commissioner for an independent review.”

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.