The Whanganui District Health Board (WDHB) has been forced to apologise and a doctor has been told to get bias training after a Māori man died from an ear infection despite repeated visits to the hospital.
The man, who was in his 30s, presented to WDHB on five occasions over two months with a recurring middle ear infection. During these visits, clinicians didn't undertake adequate investigations to understand the extent of his condition, Deputy Health and Disability Commissioner Dr Vanessa Caldwell said in a report. Health staff also didn't see whether the man had developed complications from the otitis media - an inflammation of the middle ear.
The man later died as a result of a brain abscess, which is a rare but known complication of untreated otitis media.
Dr Caldwell found WDHB in breach of the Code for Health and Disability Services Consumers' Rights for failing to provide services with reasonable care and skill. She also referred them to the Director of Proceedings to decide whether any proceedings should be taken.
She said the man had inadequate assessment and action in the emergency department, including doctors leaving out a CT head scan and not following up abnormal test results appropriately.
DHBs are responsible for the services provided by their staff, Dr Caldwell said, and the clinicians involved in the man's care "failed to appreciate the significance of his repeated presentations, and take into consideration his history of poorly resolving symptoms, and the possible presence of complications".
"Given the number of staff involved across multiple presentations, I consider that WDHB must take responsibility at an organisational level for the widespread failure in its service," Dr Caldwell said.
"These failures meant diagnosis of complications arising from the man's otitis media was delayed, and I therefore find WDHB in breach of the Code for its failure to provide services to the man with reasonable care and skill.
"It is important that ED staff ensure any suspected drug use is ruled out, so the root cause of any symptoms (which may be assumed to be due to drug use) can be explored fully."
Dr Caldwell recommended WDHB and a medical officer provide a written apology to the man's whānau.
She also made multiple recommendations to WDHB, including review and amendments of its ED on-call policy and processes for recall of patients, protocols for managing suspected drug use, provide training to staff on documentation and WDHB's expectations in relation to management of suspected drug use, and undertake an audit of positive blood cultures received by the ED to identify whether timely follow-up occurred.
She further recommended the medical officer undertake self-directed learning on bias in healthcare. She also wants him to reflect on his care in this case relating to his suspicion of drug use and the appropriate course of action, as well as his lack of documentation of discussions and observations.
Dr Caldwell also referred WDHB to the Director of Proceedings and stated that she "had regard to the particular vulnerabilities of the man and to the public interest in improving healthcare outcomes for Māori".
