A man who was later found to have eight broken ribs, a collapsed lung and internal bleeding was given a tetanus injection and sent home from a medical centre with painkillers.
Gary Wilmshurst died two days later as his family gathered for his 62nd birthday.
Coroner Ian Smith, in an inquest report on the death released today, said aspects of Wilmshurst's treatment should have been done differently.
He also said the Porirua Accident and Medical Centre, which is a joint venture between the Capital & Coast District Health Board and the Porirua After hours Medical Centre general practitioners, should make clear it was not an accident and emergency department.
And he recommended the facility consider applying the latest Advanced Trauma Life Support Course Manual for Doctors, especially noting the "pitfall" of underestimating the impact of rib fractures, particularly with older patients
His recommendations came in his report on Wilmshurst's death in December, 2011.
Coroner Smith said Wilmshurst fell from a ladder into a rock garden outside his Mana home, and was taken to the medical centre at Kenepuru Hospital in "extreme pain".
He was assessed, seen by a doctor, given a tetanus injection, prescribed pain killers, then sent home.
Despite the painkillers, he remained in pain and could barely move, and slept one night in a chair, the report said.
Two days after the fall, when Wilmshurst's family gathered for his 62nd birthday, he returned from the bathroom pale and breathing quickly, so the family called an ambulance.
Before the ambulance and fire crews arrived, the family needed to start CPR, but Wilmshurst died.
Charles Freeman, giving independent advice to the inquest, said a doctor at the centre "seriously underestimated" Wilmshurst's injuries, which were found in an autopsy to be a collapsed lung, bleeding in the chest, and eight fractured ribs – most of them likely to have been caused in the fall rather than CPR two days later.
"The rib fractures were found to be multiple with some penetrating the chest cavity," he said.
"This would have been the cause of the bleeding into the chest cavity and with his lung collapsing, which can occur some hours or days after the original injury."
These issues could lead to heart attack, he said.
In his finding, Coroner Smith said Wilmshurst died on December 28 from accidently sustaining a blunt force chest injury but was also pointed to failings by the centre.
In a separate review of the case, the Health and Disability Commissioner (HDC) had recommended that triage and documentation at the centre needed to be improved.
"I echo these sentiments and I accept that [the centre] have taken steps to rectify that but I do believe it needs to go further," the coroner said.
He agreed with Freeman that Wilmshurst's pulse and respiratory rate should have been recorded when he visited the centre, that not enough time was taken to look into what happened when he fell, and a chest X-ray should have been taken.
While the X-ray might not have shown the broken ribs, it might have and that would have increased Wilmshurst's chances of survival.
The centre needed better signage to tell people it was an accident and medical centre, not an emergency department, Smith said.
A health board spokeswoman said earlier recommendations by the HDC had been implemented.
The HDC report said nursing triage and documentation for patients in similar situations to Wilmshurst's needed to be improved and that people with suspected rib injuries should be given a pamphlet on the issue when they were sent home.
- The Dominion Post
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