KEY POINTS:
A 73-year-old man "frozen with pain" died from an infection after scraping his shin in hospital - a death considered "completely avoidable" by health authorities.
The pensioner died from septic arthritis - an extremely rare form of toxic shock - in 2004 after being discharged from a public hospital after a routine heart check-up. While in hospital he injured his shin and infection set in.
On the Tuesday he complained of a sore ankle as the infection spread. By Friday, he could not walk and was vomiting bile. A few days later he was dead.
Now his GP could face disciplinary action after an investigation found he failed to examine the patient properly and did not send the man to hospital quickly enough.
A report by Health and Disability Commissioner Ron Paterson revealed the man would still be alive if the doctor had checked the ankle.
Although the man's condition deteriorated quickly, the doctor told the inquiry he was unaware of his patient's pain - something the pensioner's family dispute. They say the ankle was so sore he could not bear to have even a sheet over it.
Dr Tony Birch, a fellow rural GP, acted as the HDC's expert adviser and says at the very least, the doctor should have looked at the wound. He questioned the doctor's "appalling" lack of medical notes.
Dr Birch agreed that septic arthritis was rare and hard to diagnose, but the symptoms were there, and he expected the patient would have survived if the doctor had reacted quicker. On-call 24 hours, seven days a week as the sole rural doctor for 2400 patients of mostly elderly Maori and lower socio-economic background, the doctor was under high levels of stress.
"I do not offer pressure of time as an excuse for the inadequacies of my medical notes in 2004, but taking into account the reality of the situation, it was certainly a factor," the doctor said.
Paterson found the doctor had breached the health code and has referred the matter to the Director of Proceedings.
