A surgeon has had to apologise to the family of a man who died of sepsis after faeces seeped through a hole in his bowel.
Health and Disability Commissioner Morag McDowell found the consultant surgeon in breach of the Code of Health and Disability Services Consumers' Rights (the Code) in a report released on Monday.
The patient, a man in his 70s, had a number of polyps removed during a colonoscopy. The following day he returned to hospital with abdominal pains and an x-ray showed his bowel was perforated.
He was moved to a larger hospital after consultants deemed it was too much of a health risk to treat him locally due to underlying health conditions.
He was stable after being transferred to the larger hospital and the surgical team decided to treat him without surgery. They thought surgery would be complicated due to the underlying health conditions.
His condition deteriorated, however the consulting surgeon, who reviewed him during a ward round on the third day, did not identify this and so the non-surgical treatment continued.
On day four his condition went downhill and he underwent surgery, which showed extensive faecal contamination from the hole in his bowel. The patient then died shortly after the surgery.
In the report McDowell accepted the decision to treat him conservatively and without surgery was acceptable, but the consulting surgeon missed an opportunity on day three to recognise his deterioration and act.
"I acknowledge that the signs of sepsis were subtle and non-typical. However, it is well documented in the clinical notes that in the preceding 24 hours, the man had multiple reviews indicating that he was not well. Based on this, and the expert evidence, a deterioration in the man's condition is evident," McDowell said.
She said the errors were a result of individual judgment and not broader issues at the hospital.
McDowell recommended the consultant surgeon provide a written apology to the family.
She also recommended the larger DHB provide training on documentation to junior staff in the surgery department, consider a review of the training provided to junior doctors on escalation following multiple reviews of a patient, and consider developing a guideline for documentation of patient handover.
McDowell further recommended it provide an update on the changes made as a result of these events, including the education provided to relevant staff on decision-making and sepsis, and the development of a sepsis programme.
