KEY POINTS:
A fresh apology is coming their way, but no amount of apologies will ease the pain for Dean Carroll's family.
When Mr Carroll, 25, staggered "like Frankenstein" into the overcrowded Emergency Department at Christchurch Hospital in April last year, he was given pain medication and sent home.
The normally fit and healthy farm worker died the next day of a spinal infection.
Health and Disability Commissioner Ron Paterson, in a critical report out yesterday, has asked the hospital bosses to follow-up their official apology to Mr Carroll's parents and partner Victoria Milne with another.
But Mr Carroll's mother, Sheree Carroll, said: "An apology isn't going to help. The person they should apologise to they can't. He's dead."
"It's over a year now and ... it just plays in my head all the time. To see Dean now I have to go down and sit by the grave."
Dean's father, Dave Carroll, said any apology was hollow when the hospital bosses were being asked to do it.
The timing of the report, a week out from Christmas, also made things more difficult. "Dean absolutely loved Christmas. He was a big kid at heart really," Mr Carroll said.
Whether his son's death had made any positive difference was still to be seen, Mr Carroll said. "Who would have confidence about going into the hospital and coming out better than you went in? It's pot luck."
CASE ONE
Whanganui District Health Board
In September 2007, a 19-year-old snowboarder fell 5m on Mt Ruapehu, fracturing his spine. He was flown to Wanganui Hospital, where the emergency department's sole doctor, who had an unreasonably heavy workload, failed to recognise the man was at high risk of permanent spinal injury. Owing to a misunderstanding, the man left before being formally discharged, deteriorated overnight and was admitted to a large public hospital. He had surgery and was transferred to a spinal rehabilitation unit, from which he was discharged last December.
Mr Paterson said he accepted the DHB's point that like other boards at the time it faced a shortage of doctors.
"That, however, does not excuse the district health board from its duty to provide an emergency department that has sufficient staff and robust systems to withstand fluctuating demands and ensure that good communication occurs between staff and with patients."
CASE TWO
Bay of Plenty DHB
In March 2007, a baby was born in Auckland following treatment during pregnancy for a blood incompatibility with her mother. In April she was transferred to Tauranga Hospital and treated for six days.
When sent home, a copy of the hospital discharge summary was not sent to a GP - the mother had not named one; nor was one given to the parents.
The necessary post-hospital monitoring for anaemia did not occur. Two days after her discharge, a blood test was taken and the result suggested a problem but it was not acted on.
Her hospital paediatrician was on leave. He saw the tests when he returned but "did not take note" of them as they were 10 days old.
In mid-May the baby deteriorated and died.
"It is clear that the blood test reporting system at Bay of Plenty DHB was inadequate," Mr Paterson said.
CASE THREE
Nelson Marlborough DHB
In mid-2007, a 49-year-old woman who had come to Nelson Hospital on a Saturday with a severe headache died there the next day from increased pressure in her brain, a rare complication of neurosurgery in 2006. It may have been possible to treat her with further surgery, although the post-mortem report says the window of opportunity for this may have been very short. She was treated for migraine. Staff did not have her medical notes from her previous
attendance at the emergency department with the same problem because they had not yet been filed in the records department. She had not been given a discharge summary, nor had her GP been given a discharge letter. She was belatedly given a CT head scan on the Sunday. The hospital physician later acknowledged he had - wrongly - been reluctant to order it on the Saturday partly because it entailed calling out two radiology staff.
CASE FOUR
Canterbury DHB
In April 2007, Dean Carroll, 25, went to Christchurch Hospital with worsening back pain after eight days of GP care and physiotherapy for a farm injury. He had a rare condition, an epidural abscess, but without typical symptoms like fever. A junior doctor prescribed a morphine injection. He went home, deteriorated and died within 12 hours.
The doctors involved were held not to have breached the code of patients' rights, but the health board was criticised for having too few staff on in the emergency department, failing to ensure proper supervision and guidance for staff and weak documentation and discharge processes.
CASE FIVE
Hutt Valley DHB
In December 2006, a 67-year-old man was taken to the Hutt Hospital emergency department after he was assaulted. He was discharged but had to go back to hospital several times. In February last year a CT head scan revealed a clot, which was removed in neurosurgery at another hospital, and he made a good recovery.
Mr Paterson criticised an emergency physician for not ordering a CT scan on the night of the assault, but also expressed sympathy for him as he was working a double-shift, "beyond the call of duty", to cope with a backlog of patients.
The emergency department had insufficient staff and the DHB must bear primary responsibility for the omissions in the patient's care.
Source: reports by Health and Disability Commissioner Ron Paterson
