Case studies - Ngā mātai take — Health & Disability Commissioner

Care provided by registered nurse in mental health unit

15 May 2025

This case concerns the care provided by a registered nurse to a man who was admitted to a hospital inpatient mental health unit. It highlights the importance of professional boundaries and ethical standards when communicating with, and caring for, vulnerable consumers.
Delay in diagnosis of cancer

17 Mar 2024

This case relates to the care provided to a woman by Health New Zealand|Te Whatu Ora Southern (Health NZ Southern). The woman presented to primary and secondary services with urinary symptoms multiple times over a five-month period. The urinary symptoms were attributed to a urinary tract infection. In the fourth month of the woman’s presentation, she was diagnosed with a rare type of cancer, known as primary mucinous adenocarcinoma of the vagina, extending to the urethra and bladder. This case considers whether the woman’s diagnosis of cancer occurred within a reasonable timeframe.
Case related to current standards and guidance for workplace assessments in safety-sensitive industries

06 Dec 2024

Deputy Health and Disability Commissioner Dr Vanessa Caldwell recently concluded an investigation into the care provided to a man by a psychologist. In investigating the matter Dr Caldwell identified concerns with the current standards and guidance for workplace assessments, particularly those undertaken for people working in safety-sensitive industries.
Family incorrectly advised that criteria for assisted death would not be met

29 Oct 2024

This case concerns access to assisted dying and determination of competence to make an informed decision to choose an assisted death. On 31 August 2021 a man who was at the end stage of a progressive, debilitating neurological disease was assessed as not expected to survive beyond four months.
Critical assessment vital when patients present on multiple occasions with the same symptoms

19 Sep 2022

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.
Appropriate systems for correct staff management of critically important medications vital for patient safety

12 Sep 2022

This case highlights the importance of aged residential care facilities having appropriate systems in place to ensure that nursing staff administer critically important medications correctly, and for medication errors to be identified and followed up in a timely manner.
Forward planning and vigilance in medication management vital to ensure continuity and quality of care of older people

12 Sep 2022

This case highlights the importance of accurate forward planning by providers for the admission of older people to care homes, and the need for vigilance to ensure that they receive their medications in a timely manner.
Providing clear information to obtain informed consent vital before undertaking procedures

08 Jun 2022

In this case, a woman visited her GP to discuss having a contraceptive intrauterine device (IUD) inserted. Several swabs and urine samples were taken prior to the procedure. When the woman arrived at her appointment to undergo the procedure the following day, a chaperone nurse noted from her computer file that the woman had a positive result for a bacterial infection, and raised it with the GP. The GP reassured the woman that the procedure would not be affected by this, and went ahead with the procedure.
Medication brand changes: highlighting systemic issues with ongoing risks to consumers

24 May 2022

In 2020, HDC received a number of complaints from consumers raising concerns about Pharmac’s decision to change the funded brand of lamotrigine, a medication used to treat epilepsy and bipolar disorder.
Investigation: delayed assessment of suicidal woman

24 May 2022

A woman had a history of depression, post-traumatic stress disorder, and significant mental health issues. She had received compulsory treatment under the Mental Health (Compulsory Assessment and Treatment) Act 1992 at the DHB.
Director of Proceedings: proceedings filed by consent in the HRRT against the Department of Corrections regarding health care provided

24 May 2022

Mr A, a person in prison, was hospitalised following a stroke and a heart attack. On discharge, the hospital prescribed him long-term clopidogrel (an antiplatelet medication or blood thinner). At the time of events, long-term clopidogrel was accepted firstline treatment for secondary prevention of stroke.
Investigation: doctor’s failure to assess mental capacity of a dementia patient

24 May 2022

A woman with dementia, and her partner, went to see the woman’s GP to complete a medical certificate certifying the woman’s mental capacity to appoint her partner as her enduring power of attorney (EPOA).
Informed consent: making recommendations for change and bringing issues to the attention of a professional body

24 May 2022

In this case, a woman complained about not being fully informed about the fertility implications of procedures she underwent — a hysterectomy and bilateral oophorectomy (removal of reproductive organs). HDC carried out a thorough assessment, with a particular focus on informed consent and the information provided on treatment options prior to the surgery.
Investigation: resident of community living home suffers burns

24 May 2022

A woman living with spastic quadriplegia, who does not communicate verbally, was a resident at an assisted living facility.
Investigation: escalation of care for rest-home resident with cardiac symptoms

24 May 2022

A woman in her late eighties was a rest-home resident and had a medical history that included coronary heart disease and COPD (a lung disease).
Delays in care: referring a complaint to a provider to resolve directly with the consumer

24 May 2022

A woman who had been diagnosed with Stage 2 myeloma (a type of blood cancer) complained to HDC about a delay in receiving her stem cell transplant procedure at her local hospital.
Mental health: referring a complaint to the advocacy process for support

24 May 2022

A woman complained to HDC about the lack of adequate mental health support she was receiving from her DHB’s mental health service. She was concerned that despite suffering a range of mental health symptoms, she had never received a definitive diagnosis and could not access community support services.
Culturally appropriate care: making recommendations and tailoring our approach to meet the needs of whānau

24 May 2022

A woman complained to HDC about the care her adult son received from a residential rehabilitation facility. He had suffered a severe traumatic brain injury following an accident, and now requires a high level of care.

Care provided by registered nurse in mental health unit

Delay in diagnosis of cancer

Case related to current standards and guidance for workplace assessments in safety-sensitive industries

Family incorrectly advised that criteria for assisted death would not be met

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

Forward planning and vigilance in medication management vital to ensure continuity and quality of care of older people

Appropriate systems for staff to correctly manage critically important medications vital for patient safety

Providing clear information to obtain informed consent vital before undertaking procedures

Medication brand changes: highlighting systemic issues with ongoing risks to consumers

Informed consent: making recommendations for change and bringing issues to the attention of a professional body

Culturally appropriate care: making recommendations and tailoring our approach to meet the needs of whanau

Mental health: referring a complaint to the advocacy process for support

Delays in care: referring a complaint to a provider to resolve directly with the consumer

Investigation: resident of community living home suffers burns

Investigation: escalation of care for rest-home resident with cardiac symptoms

Investigation: doctor’s failure to assess mental capacity of a dementia patient

Investigation: delayed assessment of suicidal woman

Director of Proceedings: proceedings filed by consent in the HRRT against the Department of Corrections regarding health care provided

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Care provided by registered nurse in mental health unit

Delay in diagnosis of cancer

Case related to current standards and guidance for workplace assessments in safety-sensitive industries

Family incorrectly advised that criteria for assisted death would not be met

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

Appropriate systems for correct staff management of critically important medications vital for patient safety

Forward planning and vigilance in medication management vital to ensure continuity and quality of care of older people

Providing clear information to obtain informed consent vital before undertaking procedures

Medication brand changes: highlighting systemic issues with ongoing risks to consumers

Investigation: delayed assessment of suicidal woman

Director of Proceedings: proceedings filed by consent in the HRRT against the Department of Corrections regarding health care provided

Investigation: doctor’s failure to assess mental capacity of a dementia patient

Informed consent: making recommendations for change and bringing issues to the attention of a professional body

Investigation: resident of community living home suffers burns

Investigation: escalation of care for rest-home resident with cardiac symptoms

Delays in care: referring a complaint to a provider to resolve directly with the consumer

Mental health: referring a complaint to the advocacy process for support

Culturally appropriate care: making recommendations and tailoring our approach to meet the needs of whānau

Care provided by registered nurse in mental health unit

Delay in diagnosis of cancer

Case related to current standards and guidance for workplace assessments in safety-sensitive industries

Family incorrectly advised that criteria for assisted death would not be met

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

Forward planning and vigilance in medication management vital to ensure continuity and quality of care of older people

Appropriate systems for staff to correctly manage critically important medications vital for patient safety

Providing clear information to obtain informed consent vital before undertaking procedures

Medication brand changes: highlighting systemic issues with ongoing risks to consumers

Informed consent: making recommendations for change and bringing issues to the attention of a professional body

Culturally appropriate care: making recommendations and tailoring our approach to meet the needs of whanau

Mental health: referring a complaint to the advocacy process for support

Delays in care: referring a complaint to a provider to resolve directly with the consumer

Investigation: resident of community living home suffers burns

Investigation: escalation of care for rest-home resident with cardiac symptoms

Investigation: doctor’s failure to assess mental capacity of a dementia patient

Investigation: delayed assessment of suicidal woman

Director of Proceedings: proceedings filed by consent in the HRRT against the Department of Corrections regarding health care provided