Two separate reports, released Monday, outlined instances where mistakes and delays harmed patients. Photo: UnSplash/ Stephen Andrews
- An elderly woman who waited four days for surgery after fracturing her leg died days after having a pulmonary embolism and a stroke during the operation
- New Zealand Health standards point towards increasing risks relating to delaying such acute surgery beyond a 48-hour timeframe
- Health NZ has been directed to apologised to another woman after lost referrals contributed to a four-month delay in diagnosing her cancer following months of symptoms
The Health and Disability Commissioner is pointing to failings in two instances in Health NZ Southern services - one where a woman died following delays to surgery, and another where lost paperwork delayed a patient's cancer diagnosis by months.
Two separate reports, released Monday, outlined instances where mistakes and delays harmed patients.
Surgical delays the 'root cause' of elderly woman's death
An investigation into the death of a 74-year-old woman - after she waited four days for surgery on a fractured femur in 2021 - identified delays as the "root cause" of the woman's death.
The woman was scheduled for surgery in Dunedin Hospital the day after she presented with a fractured femur from a fall, but the operation was initially delayed after pre-operational CT scan was not completed on time.
Limited theatre hours and high demand for priority cases over the following weekend meant her surgery was postponed until five days after the accident.
The woman suffered a pulmonary embolism and a stroke during surgery and died three days later.
Delays led to growing risk of complications
The report identified growing risks when delays for surgical repair in elderly patients with femoral fractures exceed 48 hours.
The woman's family and a GP said doctors in charge of her care were reminded of the risks when surgery was delayed for the first time.
Commissioner Morag McDowell said the woman's wait for surgery was nearly double the timeframe outlined by New Zealand health standards.
A Health NZ adverse event review said the woman's priority status remained unchanged for 84 hours, and keeping the patient on "nil by mouth" during this period may have led to dehydration which could have exacerbated risks.
McDowell said while the weekend's demand on operating theatres was unavoidable, Health NZ's systems did not support reprioritising the woman's surgery.
"Limited access to operating theatres at Health NZ Southern has been an ongoing issue for many years. However - as highlighted in this report - timely treatment for older patients with femoral fractures is particularly important for reducing the risks of morbidity and mortality," McDowell wrote.
"As the delays continued outside the guidelines, Mrs A's time waiting for surgery and increasing risk should have been taken into account when prioritising the surgical list, and/or a contingency plan should have been developed to ensure timely care."
Health NZ has apologised to the woman's family.
Health and Disability Commissioner Morag McDowell. Photo: LANCE LAWSON PHOTOGRAPHY / Supplied
Lost paperwork compounds delay
Health NZ has also been directed to apologise to a woman who waited four months to be diagnosed with a rare form of cancer.
The report on the commissioner's investigation said the patient was let down by the "absence of a robust referrals system".
The woman presented to health professionals multiple times with urinary symptoms over a five-month period in late 2023 and early 2024.
A junior registrar found a lump during a physical examination, but as the woman's GP had already requested an ultrasound
scan, the registrar did not update the referral to reflect the finding.
Paperwork for the referral was subsequently lost, which led to a four-month delay before gynaecological staff followed up.
The investigation found Health NZ Southern clinicians attributed the woman's symptoms to a urinary tract infection, and did not consider a physical obstruction in their diagnosis.
It also noted an MRI scan was terminated partway through the process due to the absence of a specialist radiologist who could report on gynaecology-related MRIs.
McDowell found that Health NZ Southern had breached the woman's rights by failing to have a robust referrals system in place.
"Since these events, Health NZ Southern has increased the resourcing within its oncology services and developed an electronic referrals system internally," McDowell wrote.
"Health NZ also made many improvements to its governance systems following the findings of the commissioner-initiated investigation."
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