KEY POINTS:
Wellington Hospital has been criticised after failing to diagnose a deadly aneurysm in an elderly woman, even though she visited the hospital four times in 10 days.
The 72-year-old died when the aneurysm ruptured while she was waiting in the hospital's emergency department.
The woman, known as Mrs A, presented with slightly different symptoms on each of the times she visited the hospital.
She was not diagnosed with a thoracic aortic aneurysm until her fourth visit.
In his report, the Health and Disability Commissioner found Mrs A was assessed by nine different doctors during her visits in April 2007.
On her final visit "Dr K" correctly diagnosed Mrs A and ordered a CT scan, but was told that because of a heavy workload, it would not be done for two hours.
Just half an hour before she was due for her scan, Mrs A collapsed and died.
Garry Clearwater, who gave independent advice to the Commissioner said he considered there were failings in hospital procedures in dealing with Mrs A.
"Diagnosis of thoracic aortic dissection or leak is very difficult.
"However, this patient had a number of 'red flags' that pointed to the possibility of vascular pathology..."
But Dr Clearwater said the aneurysm was a "serious life-threatening condition" and there was a significant chance Mrs A would have died or suffered serious disability even if it had been diagnosed before her collapse.
The report said Mrs A received generally good care, but there were several unsatisfactory aspects, including a three-day delay in getting a potentially vital x-ray to the emergency department.
Also, on the day Mrs A died an urgent CT was requested at 2pm "but the best that the radiology department could offer was 'very busy, will aim to do around (4pm)"'.
The report said there was a question about the quality of Mrs A's care as several red flags were missed and she was not reviewed by a specialist when she returned a second and third time.
Mrs A's daughter said the family knew their mother was a reasonably high risk patient.
"But by not diagnosing her condition and thereby giving her a chance at surgery, she was deprived of any chance.
"I cannot stress enough, the hospital must do more when a patients re-presents, as in Mum's case, to ED four times in total, and three of those visits within a week.
"It was distressing to us and we were powerless to make them keep her in hospital."
The Commissioner recommended the Capital and Coast District Health Board apologise to Mrs A's daughter, and it take steps to improve education of their emergency staff to recognise signs and symptoms of aneurysms.
- NZPA
