North Shore Hospital. Photo: rafaelbenari/123RF
A man in his 70s died of a cardiorespiratory arrest just two days after being discharged from Auckland's North Shore Hospital without an assessment of his need for oxygen at home.
A decision by Health and Disability Commissioner Carolyn Cooper (HDC), released on Monday, found Waitematā District Health Board (WDHB) was in breach of the patient's rights.
The man, who had a number of serious health conditions, was admitted to North Shore Hospital for 10 days in 2020 after feeling chest pain and shortness of breath. The patient had ischemic heart disease, pulmonary hypertension and chronic obstructive pulmonary disease (COPD).
He also had an extensive medical history - including having had a heart attack in 2008, a poorly functioning kidney and asthma.
The commissioner found there was no formal assessment of the man's need for oxygen therapy at home prior to his discharge.
The man returned to hospital a day after being discharged due to increasing shortness of breath overnight, and died the following day.
The commissioner said in her decision that WDHB fell short of its standards in the care of the patient, particularly around discharge planning.
She found that the hospital had a misunderstanding about the availability of oxygen at the patient's home. The medication prescribed was also not adequately reviewed, despite their adverse effects on the patient.
Cooper also found there was a lack of clear discharge advice for the patient's general practitioner.
The patient's family said they felt Health NZ "negligently discharged [the patient] into a situation which ultimately led to his death".
Health and Disability Commissioner Carolyn Cooper. Photo: Supplied
They told HDC the patient was on oxygen for the duration of his stay in hospital. They believed he should have been off oxygen for at least 24 hours prior to discharge, to ensure that he was able to tolerate breathing "room air".
Health NZ apologised to the family and said in hindsight, it recognised there was a "breakdown in communication" between the patient, his family, and staff.
The agency said the patient should have been assessed for short-term oxygen therapy, provided at discharge, for six weeks.
It said staff were working under the misunderstanding the patient was already using supplemental oxygen at home, prior to admission.
The patient's family said they did not have an oxygen supply at home.
The HDC recommended the hospital review and update its discharge policies. It also recommended it to provide education and training for staff on the importance of critical thinking during discharge planning.
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