KEY POINTS:
The Wellington coroner says he will be expecting answers from the city's health board after a man died from pneumonia at Wellington Hospital after not receiving proper treatment.
The hospital was harshly criticised by the Health and Disability Commissioner, Ron Paterson, in a report released today into the death of the 50-year-old man in September 2004.
It found that simple procedures could have saved the life of the patient, who died 40 hours after admission to the hospital with classic signs of a chest infection.
Wellington coroner Garry Evans said he would be taking up the circumstances surrounding the man's death with the Capital and Coast District Health Board, "with a view to ensuring that in the future full and complete information is provided to (my) office in relation to patient deaths."
Mr Evans said he was yet to decide whether to conduct a full inquest into the case.
He said it was the hospital's legal obligation to provide the coroner with a "full, complete and accurate account of matters".
In his report, Mr Paterson found clinical staff provided a poor standard of care before and after the chest infection was diagnosed.
There was inadequate communication, documentation and monitoring of the patient's condition, it said.
Mr Paterson said hospital staff had failed to give the coroner the "full facts" about his condition and treatment.
He also criticised the attitude of clinical staff towards the man and his family.
"The tragedy of this case is compounded by the fact that during his fatal illness, the man was denied the basic respect that ethics and the law require to be accorded to all patients."
He said the incident was a wake-up call to all DHBs, which could easily find themselves in a similar situation.
The report found:
* The man was inadequately monitored.
* His chest x-ray was not reviewed for 30 hours.
* There were "virtually no clinical observations" for the last 12 hours of the man's life.
Capital and Coast District Health Board chairwoman Judith Aitken today apologised to the man's family for their loss.
She said the board took full responsibility for the events leading up to his death.
Dr Aitken acknowledged and accepted all of Mr Paterson's criticisms of the hospital's treatment of the man.
"We have contacted the family and have met to express to them directly our apologies and deep regret."
Dr Aitken said the board would adopt all changes necessary that Mr Paterson had suggested to ensure the safety of their patients.
However, the board's actions may be a case of too little too late as Mr Paterson has taken the unprecedented step of referring the matter to the Director of Proceedings, an independent statutory officer, who will decide if CCDHB should face civil action.
"In addition to the clear systems failure, several individual doctors and nurses must accept responsibility for their failure to provide appropriate medical and nursing care," he said.
"The buck must stop somewhere."
- NZPA
