Wellington Hospital has been slated for care failings after doctors were too busy to see to an elderly woman who later died of septic arthritis.
It took five requests and 32 hours before the woman was properly reviewed by the orthopaedic team and Capital and Coast District Health Board, by which time it was too late.
A Health and Disability Commissioner's investigation was sparked after the woman's family complained about her care.
The woman, 88, came to the hospital's emergency department in 2010 complaining of a pain in her hip. She was initially diagnosed with musculoskeletal pain.
The next day, a medical house officer tentatively diagnosed septic arthritis. At that point the woman should have then received an ultrasound-guided aspiration of her hip, and review by the orthopaedic team.
But a tussle between the orthopaedic and radiology departments of the hospital ensued, with orthopaedics saying they were too busy to review the patient and recommending radiology investigate.
But radiology did not want to investigate before an orthopaedic review.
Despite being contacted several times by junior doctors, the orthopaedic team refused to review the woman and advised no antibiotics be given until radiology had looked at her.
Because of "a series of delays and miscommunications", between the orthopaedic and medical teams, nothing was done to ease the woman's pain until Saturday evening, when antibiotics were given.
When the woman was finally reviewed by the orthopaedic team on Sunday morning, it was too late. That afternoon she was diagnosed with septic shock and palliative care was the only option. She died a week later.
"There were a number of failures that led to Mrs A receiving suboptimal care and treatment at the hospital," Health and Disability Commissioner Anthony Hill said.
"While individual health professionals must take some responsibility for the failures that occurred, the failures were largely a result of broader, systems issues at the hospital."
The DHB was found to breach rights 4 (1) and 4 (5) of the Code of Health and Disability Services Consumers' Rights for failing to treat the woman in a timely way or communicate with each other.
CCDHB chief medical officer Geoffrey Robinson said the team had apologised unreservedly to the family and did so again.
"An investigation was done and we acknowledge that there were delays and missed opportunities to respond and diagnose the patient's infection and treat with intravenous antibiotics."
Since 2011 there had been several changes in processes to prevent a similar incident happening again.
This included additional training, a new patient handover process, a new information-sharing system and teaching around recognising sepsis in the elderly.
- The Dominion Post
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