The man suffered an unprecedented fall at the care home and was taken to Southland Hospital’s emergency department.
Photograph: Google Maps

• Man died of brain hemorrhage
• Hospital staff were unaware he was taking blood thinners
• HDC found Te Whatu Ora Southern and a registrar at Code of Beach
• HDC proposes formal apology from Te Whatu Ora Southern and a registrar

The Deputy Health and Disability Commissioner found Te Whatu Ora Southern and a registrar breached a man’s rights under the Health and Disability Services Consumer Rights Act after he died of a brain haemorrhage.

The man suffered an unprecedented fall at the care home and was taken to Southland Hospital’s emergency department.

The misplacement of the yellow envelope containing patient information meant hospital staff treating the man were unaware he was taking anticoagulants, commonly known as blood thinners.

The first observations of the man were made by a registered nurse about six hours after he arrived at the hospital. He was first seen by the registrar approximately nine hours after his arrival.

The registrar stated that it was usual practice for him to review the information in the yellow envelope, but there was no such information and the registrar did not order a CT scan because he was not aware that he was on anticoagulants.

The man was kept under observation and discharged to the nursing home the next day.

He became increasingly ill and was taken back to Southland Hospital; where a CT showed he suffered an intracranial hemorrhage and later died.

Deborah James said Health NZ had breached the Code by failing to provide services with reasonable care and skill.

“Health NZ did not have a clear or well-understood process for ambulance staff to deliver the yellow envelope when there was no bed available in the emergency department, resulting in the man’s yellow envelope being misplaced,” he said.

He added that the man was not evaluated for initial observations until about six hours after his arrival, and many clinicians failed to detect that he was taking warfarin.

James said these factors combined meant Health NZ was not providing the appropriate standard of care.

He also noted that because of the man’s age, frailty and head injury, a CT scan should have been completed regardless of whether he was on anticoagulants.

James recommended that both parties formally apologize to the man’s family and that Health NZ standardize the process of covering yellow envelopes when there are no beds available.

Te Whatu Ora has since increased the number of nurses working the night shift and ensured there is always a medical imaging technologist on site to scan.

The registrar also made a number of changes.

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