KEY POINTS:
The damning report into the tragic death of a man from pneumonia in Wellington Hospital is a wake-up call to all district health boards, the Health and Disability Commissioner says.
Ron Paterson found serious failings in the care the 50-year-old patient received at the hospital over the 40 hours before his death in September 2004.
Mr Paterson said 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.
Mr Paterson blamed both the failure of systems at Capital and Coast District Health Board and the individuals who failed to observe the patient properly or assess his x-rays and blood tests fast enough.
"The same fate could befall patients in other New Zealand hospitals. This case should be a wake-up call to all district health boards."
Mr Paterson noted expert advice that Wellington was unlikely to be the only hospital in New Zealand "running out-dated systems of care without the required back-up, where clinicians are frustrated by the time delays and business-case inertia that impede improvements in patient care".
The Ministry of Health's chief clinical adviser, Sandy Dawson, said system failures occurred across the health sector and tragic consequences, though rare, were not isolated incidences.
They were even inevitable given the complexities of the sector.
Mr Paterson has referred the matter to the independent Director of Proceedings in his office, Theo Baker, who will decide whether to institute legal proceedings.
Capital and Coast board chairwoman Judith Aitken said any prosecution would not be contested.
"This was a justified series of complaints against us. We've pilloried ourselves. We have not met our own standards."
Dr Aitken said the board had taken steps to address the concerns in the report, including treatment plans for patients and the handling of handover notices and x-rays.
Board representatives met the man's family this week, she said. "And they found it very moving. And awful, because the family has such a legitimate sense of grievance against us, and it's been so painful for them. And three years later, reliving those hours is very hard for anyone.
"All we can do is be deeply apologetic and say, 'This is what we're trying to do to make sure it doesn't happen again'."
Dr Aitken said some of the staff involved in the man's treatment remained at the hospital but were not facing dismissal, because being found in breach of patient care was itself severe punishment in the health system.
The hospital was also criticised for the delay in providing details of the death to the coroner, but Dr Aitken said there was no evidence of an attempted cover-up.
A sister of the man says she hopes a civil court case will hold the hospital to account.
"It's all very heartening to see they have taken it very seriously and made some big adjustments, but the fact remains that my brother is still dead."
- additional reporting: NZPA
