Elderly man dies after communication breakdown

An elderly man, whose critically abnormal blood test probably pointed to internal bleeding, died the day after the result was sent to a doctor who was away on holiday.

The man had been a patient of the Auckland District Health Board (ADHB) and a consultant there had provided an order form dated December 4 last year for testing by Diagnostic Medlab (DML). The order form was activated by his rest home and the test done on December 29, during the holiday period.

DML chief executive Arthur Morris said last night the man's haemoglobin was at an alarmingly low level.

The result was faxed, in line with the order form, to the number associated with the ADHB consultant.

"We are pretty sure a phone message was made to that consultant telling the consultant of how low the haemoglobin was. But unfortunately the person was on leave and didn't get the result till later."

The case is mentioned in the health board's report, made public yesterday.

The report says the rest home has been asked to ensure lab requests carry correct contact details and that the laboratory has been asked to review its criteria regarding communication of critical results.

The board's medical adviser on quality and safety, Dr Colin McArthur, said DML was put in a difficult position by the lack of proper information on the form. The rest home should have provided its own contact details or those of a clinician who could follow up an abnormal result. But DML also needed to look at ways of dealing with such eventualities, especially during holidays, he said.