KEY POINTS:
Wellington Hospital failed to treat a dying man and his family with respect or compassion, the Health and Disability Commissioner has found.
Ron Paterson identified serious failings in the care of the 50-year-old, who died of pneumonia 40 hours after he was admitted to the hospital in September 2004.
It is alleged the symptoms of a chest infection were not followed up and it took 30 hours for doctors to review x-rays and blood tests.
His condition was also not monitored and his health went downhill without the opportunity for simple interventions that could have saved his life.
Mr Paterson's report said there was a clear systems breakdown and several doctors and nurses must accept responsibility for their failure to provide appropriate medical and nursing care.
He believes staff and the board must accept responsibility for the man's death and he has taken the unusual step of saying the case should be considered for a civil claim.
There was inadequate communication, documentation and monitoring of the patient's condition.
"(He) was deprived of the opportunity to benefit from simple interventions that might have saved his life," Mr Paterson said.
He added: "The tragedy of this case is compounded by the fact that during his fatal illness, [he] was denied the basic respect that ethics and the law require to be accorded to all patients."
A post mortem examination showed the man died of respiratory failure and pneumonia.
A sister of the deceased said she was appalled at the attitude of one staff member in particular towards her brother after he was admitted to hospital but took some solace from the report.
"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," she said.
Management at the hospital have accepted inadequate care led to the death of the patient but will not discipline anyone in connection with the case.
Capital and Coast District Health Board (CCDHB) chair Judith Aitken this morning told Radio New Zealand the board unreservedly accepted responsibility for what happened.
Dr Aitken said the board didn't intend dismissing or disciplining the staff involved but a severe reprimand had already been delivered in the commissioner's report.
She said: "I think the effect for the four of them who have been found to be in breach is a very severe professional discipline.
"For two others the commissioner came down with an adverse opinion -- very severe in the professional life of any medical person."
Dr Aitken said an important issue to come out of the report was the need to be able to admit to, and disclose errors in judgement or practice.
"If they don't, the person who comes after them in the treatment of that person is not aware that an error has occurred. If they don't do it, overall the system can't learn.
"So we have to try and balance punitive or vindictive dismissals or disciplinary action against the need to have absolutely open disclosure, and whatever else comes out of this our board is determined that there will be an active policy of open disclosure and transparency."
Dr Aitken also admitted "inexcusable" failures led to delays in the case being reported to the coroner.
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.
Dr Aitken said any prosecution would not be defended, but the board hoped it could reach a reasonable settlement if it came to that.
- NEWSTALK ZB, NZPA, NZHERALD STAFF
