Critical assessment vital when patients present on multiple occasions with the same symptoms

This case study highlights the importance of critically assessing patients who present to hospital on multiple occasions with the same symptoms within a relatively short period of time, and investigating symptoms fully and considering alternative diagnoses.

A Māori man in his 30s presented to Whanganui DHB (now Te Whatu Ora – Whanganui) on five occasions over two months with a recurring infection of the middle ear (otitis media). During these presentations, clinicians did not undertake adequate investigations to understand the extent of the disease, or investigate whether the man had developed complications from the otitis media. Sadly, the man died as a result of a brain abscess, which is a rare but known complication of untreated otitis media.

HDC considered that the man did not receive adequate assessment and action in the Emergency Department (ED). A CT head scan was not performed, and abnormal test results were not followed up adequately. When ED staff suspected drug use by the man, this should have been ruled out, so that the root cause of his symptoms could be explored fully (and not assumed to be due to drug use).

Te Whatu Ora Whanganui is responsible for the services provided by its staff, 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 by the man to the ED, HDC held Te Whatu Ora Whanganui to account at an organisational level for widespread failures in its service. The failures in service delayed the man’s diagnosis of complications arising from the otitis media.

HDC made the following recommendations:

  • Te Whatu Ora Whanganui and a medical officer provide a written apology to the man’s whānau.
  • Te Whatu Ora Whanganui undertake reviews and amendments of its ED on-call policy and processes for recall of patients, and its protocols for managing suspected drug use; provide training to staff on documentation and its 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.
  • The medical officer undertake self-directed learning on bias in healthcare, and reflect on his care in this case relating to his suspicion of drug use and the appropriate course of action, and his lack of documentation of discussions and observations.

Te Whatu Ora Whanganui was found in breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights for failing to provide services with reasonable skill and care.

Having regard to the particular vulnerabilities of the man and to the public interest in improving healthcare outcomes for Māori, Te Whatu Ora Whanganui was referred to the Director of Proceedings for consideration of further proceedings.

Read the full decision here.