Director of Proceedings v Health New Zealand [2025] NZHRRT 1 (29 January 2025)
The Director of Proceedings filed proceedings by consent against Health New Zealand | Te Whatu Ora (“Health NZ”) (formerly Southern District Health Board (“SDHB”)) in the Human Rights Review Tribunal (“the Tribunal”) regarding the care provided to Mr A (deceased) at Dunedin Hospital.
Mr A (aged in his fifties) had a history of chronic schizophrenia and thought disorder, for which he was prescribed clozapine. He lived in a community residential mental health service run by the Corstorphine Baptist Community Trust (“CBCT”).
On 12 [Month 1] 2019, Mr A was taken to Dunedin Hospital Emergency Department (Dunedin ED) by CBCT staff after experiencing recurrent sharp abdominal pain and a three-day history of constipation and nausea. Mr A was reviewed by an ED registrar, who noted no abnormalities other than a C-reactive protein (“CRP”) of 16 and a fast heart rate of 113 beats per minute.
A rectal examination found no masses or blood, and an X-ray showed a distended transverse colon, similar to a previous X-ray completed in 2013. An ED consultant examined Mr A and noted his abdomen to be soft and non-tender. The impression was that of constipation secondary to clozapine. Mr A was discharged home that evening with laxatives and pain relief.
Following this visit, Mr A was taken to Dunedin ED six more times. Similar findings were made during the next two visits, with Mr A being discharged with laxatives and pain relief. On his fourth visit, Mr A’s pain was considered to be a result of the continued laxative use, and he was advised to discontinue.
On 3 [Month 2] 2019, Mr A arrived by ambulance at Dunedin ED with abdominal pain. This was his fifth visit in three weeks. Mr A was reviewed by the ED Senior Medical Officer, who queried the possibility of a large bowel obstruction. Mr A was then admitted to the General Surgery ward. with a plan to keep Mr A in hospital for observation and pain relief. He was discharged on 6 [Month 2] 2019 after passing gas, eating breakfast and having minimal abdominal pain with stable observations.
On the morning of 13 [Month 2] 2019, Mr A reported to CBCT staff that he was not feeling well. By that afternoon, CBCT staff noted that Mr A was in “obvious distress”. An ambulance was called, and Mr A was taken to Dunedin ED for a sixth time with a “very tight and distended” abdomen. Mr A was reviewed at approximately 5pm.
On examination, Mr A’s abdomen was distended with high-pitched bowel sounds. Blood tests showed an elevated CRP and low haemoglobin levels, indicating a slightly reduced red blood cell count. Mr A was admitted for observation and was discharged on 16 [Month 2] 2019 with a primary diagnosis of clozapine-related constipation and a pseudo-obstruction. Mr A was to follow up with his GP, continue laxative medication, and have repeat blood tests to check his kidney function.
On the morning of 24 [Month 2] 2019, CBCT staff requested an ambulance for Mr A as again he was complaining of increased pain in his abdomen. On examination in Dunedin ED, his bowel sounds were noted to be “very very very scant”. He had a high heart rate at 115 beats per minute and a CRP level of 65. The impression was that of an obstruction, potentially related to clozapine, and Mr A was admitted and referred to general surgery.
On 27 [Month 2] 2019, Mr A woke up and vomited a small amount of brown faecal-looking liquid. The night nurse documented that he appeared pale, with a rigid and distended abdomen. That afternoon, Mr A became more distressed and agitated, with increasing pain. Blood tests showed an increased CRP to 149, a high lactate of 9.6, and increased potassium and sodium levels.
Mr A’s clinical deterioration and his worsening test results led to the decision to surgically examine Mr A’s abdomen for a presumed large bowel obstruction. During the operation, Mr Awas found to have widespread colon cancer with tumours that had caused a complete bowel obstruction.
Mr A was transferred to the intensive care unit after surgery, but he made very little progress postoperatively. Given the operative finding of extensive metastases, and the poor prognosis, palliative care was commenced.
Sadly, Mr A died the evening of 1 [Month 3] 2019. His cause of death was septic shock, secondary to metastatic colon cancer.
Independent expert advice provided to the Health and Disability Commissioner considered that the deviation in care stemmed from the lack of consideration of an alternative diagnosis when Mr A continued to present with unresolved symptoms despite adequate initial care. The expert also noted the lack of further investigation by staff when Mr A continued to present to Dunedin ED with persistent and similar symptoms. Lastly, the expert observed that there was an unsatisfactory investigation of Mr A’s newly onset symptoms which did not settle with adequate treatment. This was compounded by the lack of further investigation following Mr A’s abnormal CT result on his sixth admission.
Health NZ accepted that its failures breached the Code of Health and Disability Services Consumer’s Rights (“the Code”) and the matter proceeded by way of an agreed summary of facts. The Tribunal was satisfied that Health NZ failed to provide services to Mr A with reasonable care and skill and issued a declaration that it breached Right 4(1) of the Code.
The Tribunal subsequently granted a permanent order prohibiting publication of Mr A’s name and identifying details.
The Tribunal’s full decision can be found at:
2025-NZHRRT-1-Director-of-Proceedings-v-Health-New-Zealand-Redacted.pdf .