Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

1. On 16 June 2022, the Health and Disability Commissioner (HDC) received a complaint from Mr A about the care provided to his wife, Mrs A, by Health New Zealand | Te Whatu Ora (Health NZ) before she died in May 2022 after experiencing a brain bleed. Mrs A was aged 66 years at the time. I extend my sincere condolences to Mrs A’s whānau for their loss.
   
   

Information gathered

2. On 22 December 2021, Mrs A presented by ambulance at her rural hospital’s emergency department (ED) with left-sided limb dysfunction, numbness, difficulty speaking, palpitations, and buzzing in her right ear. Mrs A’s symptoms resolved while she was in the ED, and it was suspected that she had experienced a transient ischaemic attack (TIA).[1]
   
   
3. Mrs A was transferred to a secondary-level regional hospital and admitted to the General Medicine ward. A computed tomography (CT)[2] scan was performed to evaluate the suspected TIA. The CT scan showed no evidence of a new stroke. However, it identified an incidental finding of a suspected saccular aneurysm.[3]
   
   
4. On 23 December 2021, in light of the suspected aneurysm, Dr B sought advice from a tertiary hospital neurosurgery registrar, Dr C.[4] Dr C confirmed that Mrs A should continue to receive dual-antiplatelet therapy[5] to reduce the risk of a subsequent stroke, and a plan was made for Dr C to call back to provide further advice.
   
   
5. On 24 December 2021, Dr C called Dr B and recommended that a CT angiogram (CTA)[6] be performed. Dr B recorded in the clinical notes that Dr C also advised that Mrs A’s case would be discussed by the neurosurgical team, and Mrs A would be contacted regarding follow-up care.
   
   
6. The CTA was completed on 24 December 2021 and confirmed the diagnosis of a saccular aneurysm. It appears that this result was not communicated to the tertiary hospital neurology department. On the same day, Mrs A was discharged from the secondary-level regional hospital with three weeks’ of dual-antiplatelet medication. Mrs A’s discharge summary stated that her case would be discussed by the tertiary hospital neurosurgery department, and that she would ‘receive a letter or phone call from neurosurgery for outpatient clinic follow up’.
   
   
7. Mr A told HDC that in February 2022 he and Mrs A followed up about the neurosurgery appointment and were told that no appointment had been made.
   
   
8. In early May 2022, Mrs A collapsed while playing golf. She experienced vomiting, a low heart rate, and difficulty breathing. Mrs A was taken by helicopter to the tertiary hospital. It was confirmed that her aneurysm had ruptured, causing a severe subarachnoid haemorrhage.[7] Sadly, Mrs A did not show signs of neurological recovery. Mrs A’s whānau agreed that the focus of treatment should be changed to palliative care[8] only, and she died shortly afterwards. Again, I offer my heartfelt condolences to Mrs A’s whānau for this tragic outcome.
   
   
9. Health NZ told HDC that there was an assumption made that Mrs A would be seen by the tertiary hospital’s neurosurgery department, based on Dr B’s phone discussion with Dr C. However, Health NZ was unable to find any evidence that a written referral was sent to the tertiary hospital neurosurgery department. Health NZ acknowledged that its referral process was inadequate and has apologised. Health NZ also noted that it does not have an electronic referral management system for referrals to the tertiary hospital (its tertiary care provider).
   
   
10. The tertiary hospital told HDC that it does not have any record of the discussions between Dr B and Dr C and that no referral was received. No further information could be sought from Dr C as he left New Zealand and could not be contacted. The tertiary hospital said that its first involvement in Mrs A’s care was when she presented acutely in May 2022.
    
    

Responses to provisional decision

11. Mr A was given the opportunity to respond to the provisional decision. He confirmed that, with frustration, he accepts the findings of this report. Mr A said that even though fault has been found in the care provided, it is of little comfort to him and his family. He noted that his family are lay people and rely heavily on the health system to protect them. They trusted the system that was in place, but in this case, it failed them.
    
    
12. Health NZ was given the opportunity to respond to the provisional decision. Health NZ told HDC that it accepts the feedback and recommendations made in this report, and that it has no further comments to make.
    
    

Opinion: Health NZ — breach

13. Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code) states that every consumer has the right to have services provided with reasonable care and skill. Based on the information gathered during the investigation, it is evident that the care provided to Mrs A by Health NZ was not of an appropriate standard.
    
    
14. When it was suspected, and then confirmed on 24 December 2021, that Mrs A had a saccular aneurysm, it was appropriate for advice to be sought from the tertiary hospital’s neurosurgical team. I acknowledge that the ensuing discussions gave the secondary-level regional hospital staff the impression that Mrs A’s case would be discussed by the tertiary hospital neurosurgical team and that follow-up care would be arranged.
    
    
15. Despite the fact that what amounted to a verbal referral of Mrs A’s care had been made by Dr B, I consider that it remained the responsibility of the secondary-level regional hospital staff to make a formal written referral to the tertiary hospital neurosurgery department and that this was a required action. Written referrals support safe practice for several reasons. They allow the referring clinician to convey important and relevant information, such as patient details, records, and test results. Written referrals also ensure that there is certainty that a referral is being made, and the accepting team can in turn provide a written acknowledgement of the referral being received. As this case shows, without a formal written referral being made, there is no auditable ‘paper trail’. This can lead to patients, such as Mrs A, being overlooked and not receiving the necessary care in a timely manner.
    
    
16. I am concerned that the secondary-level regional hospital had inadequate systems in place to support staff to ensure that the appropriate written referral was completed before Mrs A was discharged. This could include electronic reminders upon discharge, a discharge checklist, and a field in the discharge paperwork prompting clinicians to complete a written referral if appropriate.
    
    
17. I am critical that no written referral was made by the secondary-level regional hospital to the tertiary hospital neurosurgery department, which meant that Mrs A did not receive the neurosurgical follow-up care she required. I therefore find that Health NZ breached Right 4(1) of the Code.
    
    

Recommendations and follow-up actions

18. I recommend that Health NZ provide a formal written apology to Mrs A’s whānau for the issue identified in this report. The apology is to be sent to HDC within three weeks of the date of this report, for forwarding to Mrs A’s whānau.
    
    
19. I recommend that Health NZ establish a protocol to ensure that, in addition to any verbal referrals to other services, written referrals are also completed. This can be included in an already established or newly created process. A copy of the relevant protocol or process should be sent to HDC within three months of the date of this report, along with details of any training or education provided to staff on this matter, if applicable.
    
    
20. I recommend that Health NZ consider the implementation of an electronic referral system for referrals to the tertiary hospital specialist services. A copy of the report on this matter should be sent to HDC within three months of the date of this report.
    
    
21. A copy of this report with details identifying the parties removed, except Health NZ, will be sent to the Health Quality & Safety Commission and the Ministry of Health | Manatū Hauora and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.
    
    
    
    
    

Carolyn Cooper

Deputy Health and Disability Commissioner