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Names have been removed (except MidCentral DHB, Palmerston
North Hospital, Horowhenua Hospital, Capital and Coast DHB,
Wellington Hospital) to protect privacy. Identifying letters are
assigned in alphabetical order and bear no relationship to the
person's actual name.
MidCentral District Health Board
Capital and Coast District Health Board
A Report by the Health and Disability Commissioner
In December 2006, Mr B was diagnosed by MidCentral DHB general
surgeon Dr C as having carotid artery disease that required
specialist surgery. Dr C referred Mr B to Capital and Coast DHB
vascular surgeon Dr D on 6 December 2006.
On 17 October 2007 Mr B attended his GP, who realised that Mr B
had not yet been assessed by a vascular surgeon. Accordingly, the
GP contacted Dr C's registrar, who sent a second referral to Dr D
on 5 November 2007.
Capital and Coast DHB has no record of receiving either
This report considers the standard of care provided to Mr B at
MidCentral DHB, the responsibility of a referring DHB to ensure
that a referral to another DHB is followed up, and the
responsibility of a receiving DHB to log, acknowledge and monitor
Mr A, Complainant/Consumer's son
Mr B, Consumer
Dr C, General surgeon (MidCentral DHB)
Dr D, Vascular surgeon (Capital and Coast DHB)
Dr E, Registrar (MidCentral DHB)
Dr F, Consumer's GP
Dr G, Medical officer (Horowhenua Hospital)
MidCentral DHB, Provider
Capital and Coast DHB, Provider
Complaint and investigation
On 15 November 2007 the Health and Disability Commissioner (HDC)
received a complaint from Mr A about the services provided to his
father, Mr B, by MidCentral District Health Board. The following
issue was identified for investigation:
The appropriateness of the care provided by MidCentral
District Health Board to Mr B from December 2006 to December 2007,
in particular the management of Mr B's referral to Capital and
Coast District Health Board.
An investigation was commenced on 27 March 2008. Information was
received from Mr A, Dr E, Dr F, MidCentral DHB, Capital and Coast
DHB, and the Ministry of Health. Independent expert advice was
obtained from vascular surgeon Professor Justin Roake.
Information gathered during investigation
After a small stroke in August 2006 at the age of 72, Mr B was
referred on 3 August by his general practitioner at a medical
centre, Dr F, to MidCentral DHB's Elder Health outpatient clinic at
Horowhenua Hospital for further investigations. (He had not
required admission to hospital.)
On 14 August 2006, Mr B was reviewed at Horowhenua Hospital by
medical officer Dr G, who ordered a CT scan of the head,
echocardiogram and ultrasound scan of the carotid arteries. On
receipt of the results of these investigations, Dr G referred Mr B
on 9 November 2006 to the vascular surgeon at Palmerston North
Hospital. Subsequently, Mr B was reviewed
at Palmerston North Hospital by general surgeon Dr C on 5 December
2006. Dr C stated:
"I saw [Mr B] in my Surgical
Outpatient Clinic on 5 December 2006. He suffered a [stroke] a few
months prior to that visit. He had left sided hemiparesis
[paralysis] from which he had made a reasonably good recovery.
Subsequent Duplex scan of his carotid arteries revealed right sided
internal carotid artery stenosis of 70-80% on the right and 50-70%
on the left side.
I had a thorough discussion with [Mr
B] regarding the … findings and referred him on to the Vascular
Unit at Wellington Hospital for further management. We do not do
carotid surgery … at Palmerston North Hospital, hence the referral.
[Mr B], in the meantime, was on Aspirin and Persantin to decrease
the risk of further strokes."
Dr C sent a letter on 6 December 2006, referring Mr B to
vascular surgeon Dr D at Wellington Hospital, and requesting
"further intervention for carotid artery stenosis".
Capital and Coast District Health Board (CCDHB) has no record
that this referral for vascular surgery was received, and Dr F did
not receive a copy of the referral letter at the time.
Mr B consulted Dr F on 4 April 2007 on an unrelated matter and
mentioned that he had not yet received an appointment from
Wellington Hospital. The practice nurse was asked to follow this
up, and subsequently sent an email back to Dr F which stated: "…
apparently on list in Wellington for surgery no time line for this
yet". Following a specific request from the medical centre in
mid-April 2007, MidCentral DHB sent Dr F a copy of the December
2006 referral letter to Wellington Hospital.
Ten months later, on 17 October 2007, Mr B attended the medical
centre and was reviewed by another doctor, who noted that Mr B
"still has postural [low blood pressure] and dizziness". The doctor
also noted that Mr B had not been contacted by the vascular
surgeons at Wellington Hospital. Accordingly, on 18 October 2007
the doctor wrote to the surgical outpatients clinic at Horowhenua
Hospital (part of MidCentral DHB):
"Thank you for seeing [Mr B] with
bilateral internal carotid artery stenosis. He has been seen by
Surgery last … December and they were going to refer him to a
vascular surgeon. He hasn't heard anything from them since then. I
will appreciate if you can advise us on the progress of his
referral or further management."
On 2 November 2007, Dr C's registrar, Dr E, wrote to Dr F:
"Thank you very much for bringing to
our attention that [Mr B] is still awaiting a vascular opinion in
Wellington. I have chased up the paperwork and we note that [Dr C]
had referred [Mr B] to [Dr D] in December 2006.
We have organised to send another
copy of this letter as it may have been lost in the system. We hope
that [Dr D] can see [Mr B] on an urgent basis."
In a letter dated 5 November 2007, Dr E wrote to Dr D repeating
the referral of 6 December 2006. Dr E asked
that Mr B be seen urgently because of the delay caused by the
earlier referral having been lost. CCDHB has no record that this
second referral was received.
On 11 November 2007, Mr B was admitted to Palmerston North
Hospital having suffered a further stroke that affected the right
side of his body.
Mr B's son, Mr A, complained to HDC in November 2007. In his
letter of complaint, Mr A asked:
- How can such important communications be lost in transit on two
occasions? Why is there no process in place to ensure such
communications are received by the intended recipient?
- Why did Palmerston North Hospital wait a full 10 months to
follow up the first letter? Surely if they did not hear after a few
weeks, they should have sent an email or placed a call directly
with the intended recipient.
- How can Wellington Hospital not commit to performing the
potentially life saving surgery on my father now that it is obvious
that there has been such a catastrophic failure on the part of the
- How can the Palmerston North Hospital not commit to providing
my father with the best available rehabilitation given that they
jointly must shoulder the responsibility for my father's
Mr A stated:
"My father, and indeed all New Zealand residents, are clients of
the New Zealand health system … Given that my father is now
severely disabled and now presumably has a much shortened life
expectancy as a result of this failure on the part of the health
system, I make the following recommendations:
- The health system as a whole is declared culpable for the
failure that has resulted in my father's current predicament.
- Individual parties within the health system are identified and
held accountable for this culpability.
- A recommendation is made for my father to receive extensive
compensation due to this failure.
- An initiative is undertaken to put in place a reliable booking
and messaging system within the health system that delivers an
electronic message brokering system whose functional requirements
District health board responsibilities
MidCentral DHB (MCDHB) has no system to check that a referral
made to another district health board is received and actioned.
"Across all services, MidCentral
Health assumes that a written referral has been received. The only
process that provides confirmation is when a surgeon makes direct
contact with the receiving consultant, or the surgeon requests a
follow-up appointment with the patient at his clinic, requested at
the time of referral. …
MidCentral Health receives written
confirmation from the DHB once a patient has been seen or treatment
In order to ensure receipt of
patient referrals by tertiary centres, either MidCentral Health
would need an electronic flag system that raised an alert to prompt
a manual investigation, or the receiving DHB would have to adjust
their processes to return confirmation."
CCDHB advised HDC that all referrals come through a Booking
Centre, and are registered within 24 hours of receipt before they
are sent to the service for prioritisation. Once prioritised, the
referrals are sent back to the Booking Centre and acknowledgement
letters are sent to the patient and GP (but not the referring DHB)
within 10 days.
The Ministry of Health advised HDC that, as part of its national
service specification for DHB elective services, there is no
specific requirement for a service receiving a referral to
acknowledge receipt if the referrer is not the patient's primary
care practitioner. The Ministry also advised that DHBs are required
to "appropriately acknowledge and process all patient referrals
within 10 working days".
Independent advice to Commissioner
The following expert advice was obtained from vascular surgeon
Professor Justin Roake:
"I have been asked to provide
independent expert advice to the Health and Disability Commissioner
about whether MidCentral DHB provided an appropriate standard of
care to [Mr B] (Ref 07/20199).
I have read and agree to follow the
Commissioner's Guidelines for Independent Advisors.
My qualifications are MBChB (Otago),
DPhil (Oxon), FRACS(Vasc), FRCS, and I have training and experience
in the theory and practice of peripheral vascular surgery. I was
consultant vascular surgeon at the John Radcliffe Hospital, Oxford,
UK from 1992 to 1997. In September 1997 I was appointed to the
Chair of Surgery, Christchurch, NZ, and have practised as a
consultant vascular surgeon at Christchurch Hospital continuously
since my appointment. … I am vocationally registered in general and
vascular surgery in New Zealand.
I have no conflict of interest with
respect to this complaint.
[At this point Professor Roake lists the information provided to
him and a précis of the case. He also lists the questions asked of
him, which are repeated in his report. This information is omitted
from this report for the purpose of brevity.]
1. Please comment generally on the care
provided to [Mr B] by MidCentral DHB.
- The care provided by MidCentral DHB appears to have been of an
appropriate standard. [Dr C] made an appropriate referral to [Dr D]
as a result of the consultation on 5 December 2006. He recognised
that [Mr B] might benefit from surgical treatment of his carotid
artery broadly in line with clinical evidence (summarised below)
obtained from randomised controlled trials.
- The most reliable evidence for management of symptomatic
carotid artery stenoses is obtained from the combined analysis of
two large multicentre randomised controlled trials (NASCET and
ECST) published in the Lancet by Dr Peter Rothwell in 2003 and 2004
(Lancet 2003; 361: 107-16 and Lancet 2004; 363: 915-24). This
evidence is important for understanding whether or not appropriate
care was delivered in [Mr B's] case. The clinical trials show that
carotid endarterectomy can significantly reduce the risk of stroke
related to a carotid stenosis if:
- The degree of stenosis exceeds
approximately 50% and
- The procedure is performed within
a relatively short time of a sentinel event- a stroke or transient
ischaemic attack (TIA) referable to the stenosed artery. In a male
this would generally be within 12 weeks of an event related to a
>70% stenosis or within 2 weeks of an event related to a 50-70%
- The clinical benefit of carotid
endarterectomy for asymptomatic stenoses or temporally remotely
symptomatic stenoses (more than 3-6 months) is either small or
- This evidence leads to management of carotid artery disease
that may appear to be counterintuitive - urgent management if there
have been recent symptoms but non-urgent management if with the
passage of time there have been no further symptomatic events
related to the carotid disease.
- At the time [Mr B] was seen by [Dr C] he had had a stroke
referable [to] a 70-80% stenosis in the right carotid artery 3 to 4
months earlier. Technically this falls just outside the window
where substantial benefit from surgery might be expected.
Nevertheless referral to a specialist vascular surgeon was
- In general mail is a reliable means of communication. Given the
volume of clinical correspondence it is not feasible for DHBs to
keep track of all correspondence. However, as in this case, the GP
and patient have a role in ensuring that action occurs in a timely
2. Please comment on the adequacy of the actions
taken by MidCentral DHB medical staff once they became aware that
the referral of 5 December 2006 had not been received by Capital
and Coast DHB. In particular, please comment on the time taken to
act following alert by the GP, and whether there should have been
more urgent communication with CCDHB, such as by
- When MidCentral DHB medical staff became aware that the first
referral had not been received by Capital and Coast DHB it was 10
months after [Mr B's] original consultation with [Dr C] and 13-14
months after the sentinel event leading to the referral to [Dr
- As noted above any clinical urgency had dissipated through the
passage of time and the actions of the medical staff involved
appear to have been entirely appropriate. There was no particular
need for a telephone referral.
3. In the circumstances where the first
referral had been 'lost', should any additional actions have been
taken by the referring clinicians to ensure the second referral of
5 November 2007 was received?
- There was no particular reason to suppose that the second
referral would be lost. As noted above the mail system is generally
reliable and in this case the second referral was less urgent than
4. Any other comments you wish to make
It is unfortunate that [Mr B] suffered a second [cerebrovascular
accident] without first having the benefit of a specialist opinion.
However the actions taken by MidCentral DHB medical staff appear to
have been appropriate. It is difficult to understand how clinical
correspondence to Capital and Coast DHB could be 'lost' on two
occasions and this raises questions on the effectiveness of their
systems for handling incoming referrals."
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability
Services Consumers' Rights are applicable to this complaint:
Right to Services of an
(1) Every consumer has the right to have services
provided with reasonable care and skill.
(5) Every consumer has the right to co-operation
among providers to ensure quality and continuity of
Opinion: Breach - MidCentral District Health Board
Mr B suffered a stroke in November 2007 that may have
been prevented had he been assessed in a timely manner by a
specialist vascular surgeon at Wellington Hospital. Although the
original referral had been made eleven months earlier, because of
inadequate systems at MidCentral DHB that failed to check that the
referral had been received and was being actioned by Capital and
Coast DHB, Mr B fell through the cracks in the system.
Mr A is right to ask, "How can such important communications be
lost in transit on two occasions? Why is there no process in place
to ensure such communications are received by the intended
recipient?" The simple answer is that there should have been such a
process and his father's referral should never have been lost. This
case highlights the need for the development of a single electronic
health record and record management system in New Zealand, which
could provide automatic electronic tracking of referrals and
appointments together with the capacity for all health providers
(including GPs and patients) to view the progress of referrals in
the system and appointments made.
I repeat what I have stated in another case investigated
concurrently with Mr B's: this case should be a wake-up call for
all district health boards to improve their systems for handling
inter-DHB referrals. Leadership at a national level will be
essential for this to occur. Changes are clearly needed to
referring and receiving practices if boards are to fulfil their
duty of care for patients.
Duty of care - general principles
District health boards owe patients a duty of care in handling
outpatient referrals, under Right 4(1) of the Code of Health and
Disability Services Consumers' Rights (the Code). This duty applies
no less to referrals from other DHBs (inter-DHB referrals) than to
those from GPs within their district. A specific aspect of the duty
of care is the duty to co-operate with other providers to ensure
continuity of care, under Right 4(5) of the Code.
In meeting this duty of care, it would seem necessary for a
referring district health board to: (1) copy all referrals to the
patient and their general practitioner, and (2) have a system in
place to ensure that a referral has been received (and follow it up
in the absence of confirmation of receipt) and that care of the
patient has been accepted by the receiving district health
Receiving district health boards owe referred patients a duty of
care to: (1) acknowledge receipt of the referral, (2) prioritise
it, (3) arrange for patients to be seen in
a timely fashion, in their assigned priority, and (4) keep the
patient and his or her GP informed whether, and if so when, the
patient will be seen.
As I noted in a concurrent case:
"It is not for HDC to prescribe the
correct solution to these problems. But it is my job to state the
obvious: whatever referral system is operating between district
health boards, it has to work for patients, who should have
justified confidence that referrals will lead to action in
sufficient time to treat preventable problems that the public
system undertakes to treat."
My independent vascular surgery advisor, Professor Justin Roake,
advised that the clinical decisions made by the medical staff at
MidCentral DHB regarding Mr B's care were of an appropriate
standard. The decision to refer Mr B for vascular surgery was
correct, and the referrals were properly made. Professor Roake
advised that, counterintuitively, once it was realised that the
first referral had been lost, there was no clinical reason to make
the second referral in a more urgent fashion (given the passage of
time without further symptomatic events related to the carotid
artery disease). I accept Professor Roake's advice and, in relation
to Mr B's clinical care, I conclude that MidCentral DHB did not
breach the Code.
Although the actual clinical care provided was of an appropriate
standard, I am concerned by the failure of MidCentral DHB to take
follow-up action when a vascular surgery review did not eventuate
within a reasonable time following the referral of 6 December
Mr B was referred for vascular surgery on 6 December 2006 by the
MidCentral DHB surgeons. The referral was apparently never received
by Capital and Coast DHB. There is no system at MidCentral DHB for
tracking referrals to another DHB to ensure they have been received
and that care of the patient has been accepted. Since Capital and
Coast DHB does not send an acknowledgement of receipt of the
referral to the referring DHB, it was not known (and should not
have been assumed) by the referring MidCentral DHB surgeons that
the referral had been received.
The Ministry of Health advised HDC that it imposes no
requirement on district health boards to track the progress of
referrals for elective services. Furthermore, it is apparently the
norm in New Zealand for a DHB to have no system to track a referral
to another DHB.
The absence of any contractual specification is not
determinative of the extent of a DHB's duty of care. Nor does the
fact that 21 DHBs fail to track referrals make this an appropriate
standard of care. In the same way that individual providers such as
GPs are responsible for ensuring that referrals are received, and
care of the patient accepted, so too DHBs
owe patients a duty of care to follow up referrals to other DHBs. I
accept my expert's point that GPs and patients themselves have a
responsibility to see that "action occurs in a timely fashion", although they can
hardly "ensure" action. In any event, it should not be left to them
to ensure that a referral from one DHB to another has been received
and care accepted. That responsibility lies with the referring
MidCentral DHB failed to follow up the December 2006 referral
and check that it had been received and was being actioned by
Capital and Coast DHB. MidCentral DHB had no system in place to
track its referrals to other DHBs. As a consequence, MidCentral DHB
failed to coordinate the provision of Mr B's care with Capital and
Coast DHB in handling the referral. In these circumstances,
MidCentral DHB breached Rights 4(1) and 4(5) of the Code.
MidCentral DHB accepts that it breached the Code, and will be
apologising to Mr B. It is currently reviewing its system for
handling referrals to other DHBs.
Responsibility of receiving DHB
It is surprising that Capital and Coast DHB apparently received
neither of Mr B's two referrals. It may be that the first letter
(in December 2006) was not sent, since a copy was not received by
Mr B's GP at that time. However, it seems probable that the second
referral (in November 2007) was sent, since a copy was received by
Mr B's GP at that time. Even though Capital and Coast DHB has no
record of receiving the referrals, it is difficult to believe that
neither referral arrived.
Capital and Coast DHB advised that had the referral letters been
received, they would have been registered within 24 hours of
arrival before being prioritised, and an acknowledgement letter
sent to Dr F and Mr B. This did not happen.
I share Professor Roake's view that this case raises questions
about the effectiveness of the systems used at Capital and Coast
DHB for handling incoming referrals. In my view, receiving DHBs owe
a duty of care to referred patients to have an efficient and
reliable system in place to electronically log referrals,
acknowledge receipt from the referrer, and monitor referrals from
all sources, including other DHBs.
The Ministry of Health requires DHBs to "appropriately
acknowledge and process all referrals within 10 working days". In
my view, a receiving DHB should acknowledge receipt of the
referral, promptly notify the patient (with a copy to the patient's
GP and to the referring DHB) of an approximate timeframe for an
appointment, and then notify the patient (again, with a copy to the
GP and referrer) of a specific appointment time.
If the referring DHB also has a system to routinely check that
there are no outstanding referrals, this will close the loop and
should ensure that referrals do not go astray. I comment in more
detail on a receiving DHB's responsibility in a concurrent case.
Responsibility of general practitioner
This case involves the referral of a patient from one DHB to
another. It also provides a salutary reminder that GPs have a key
role to play in following up referrals to check that they are
actioned promptly. For most patients, their GP is the health care
provider who is best placed to keep an overview of their care. As
noted in the Southland urology case, the referring GP "retains a
duty of care for the ongoing clinical management of the patient
pending specialist assessment". An aspect
of this duty is actively following up a referral for a patient who
is still awaiting a further specialist assessment. Although primary
responsibility for such follow-up lies with the referring DHB, I
consider that the GP retains a residual responsibility to monitor
the progress of the patient through the system.
Dr F, Mr B's GP, pointed out that in this case the referral made
by her (in August 2006) and followed up by another GP from the
medical centre (in October 2007) was directed to the surgical
outpatients clinic at Horowhenua Hospital (part of MidCentral DHB).
Medical officer, Dr G, at Horowhenua Hospital undertook various
investigations and on-referred Mr B to Palmerston North Hospital
(another part of MidCentral DHB). This in turn led to the two
referrals by MidCentral DHB to Capital and Coast DHB (in December
2006 and November 2007).
I accept Dr F's point that:
"[t]he number of referrals between
Elder Health Horowhenua Hospital, Surgical Outpatients, Palmerston
North Hospital radiology departments and Wellington Vascular
Surgeons are numerous. The logistics required for a non-referring
general practice to actively follow up these referrals are vast.
[Our] practice did not have any knowledge of the December 
referral until we requested it in mid-April. At that time the delay
in seeing surgeons in Wellington was not out of the ordinary."
However, even when there are intermediate referrals, I consider
that a patient's GP retains a residual responsibility to monitor
the progress of the patient through the system.
In this case, the medical centre did take some steps to monitor
and expedite Mr B's referral to the Wellington vascular
Ethical responsibility of DHBs
In his complaint, Mr A suggested that MidCentral and Capital and
Coast DHBs should "commit to providing my father with the best
available rehabilitation given that they jointly must shoulder the
responsibility for my father's predicament".
Although it cannot be proved that the delayed referral caused Mr
B's second stroke, there is no doubt he was badly let down by the
poor systems in place at MidCentral and Capital and Coast DHBs. In
my view, MidCentral and Capital and Coast DHBs have an ethical
responsibility to ensure that he receives all appropriate health
care from this point onwards.
- I recommend that MidCentral DHB apologise to Mr B for its
breaches of the Code.
- I recommend that MidCentral DHB review its referral system in
light of this report, and advise HDC of the outcome of its review
by 31 January 2009.
- I recommend that Capital and Coast DHB review its system for
handling incoming referrals in light of this report, and advise HDC
of the outcome of its review by 31 January
- I recommend that the Ministry of Health review the current
system of inter-DHB referrals, and advise HDC of the outcome of its
review by 31 January 2009.
- A copy of this report, with details identifying the parties
removed (other than MidCentral District Health Board, Palmerston
North Hospital, Horowhenua Hospital, Capital and Coast District
Health Board, Wellington Hospital and HDC advisor Professor Roake),
will be sent to the Minister of Health, the Quality Improvement
Committee, the Health Information Strategy Action Committee, the
Director-General of Health, the Royal Australasian College of
Surgeons, the Royal New Zealand College of General Practitioners,
and all district health boards, and will be placed on the Health
and Disability Commissioner website, www.hdc.org.nz, for educational
 The referral letter was copied to Dr
 Carotid artery stenosis: A narrowing
of the carotid artery.
 The referral letter of 5 November
2007 was copied to Dr F.
 This point was made by Auckland DHB
in case 07HDC19869 (3 October 2008).
 See Opinion 07HDC19869 (3 October
 As noted in the Southland urology
case 04HDC13909 (4 April 2006), prioritisation systems should be
"fair, systematic, consistent, evidence-based and transparent"
(citing "Statement on safe practice in an environment of resource
limitation" (Medical Council of New Zealand, 2005)).
 As noted in the Southland urology
case, district health boards have a duty to appropriately manage
and monitor their waiting lists. See 04HDC13909 (4 April 2006),
 Case 07HDC19869 (3 October
 See discussion below in relation to
a GP's responsibility.
 Involving patients at all stages
of the communication process provides a valuable safeguard to
prevent communications going astray.
 See 07HDC19869 (3 October
 See footnote 5.