Health watchdog finds failures led to man's death in Dunedin Hospital

Health New Zealand has been found to have failed in ensuring a timely assessment and diagnosis for a man who died in Dunedin Hospital. The man, identified as Mr A, died a short time after undergoing an above-knee amputation following a diagnosis of acute limb ischaemia.

Mr A was admitted to the hospital on 18 March 2021 after injuring his elbow in a fall at home. He had a significant medical history including diabetes, peripheral vascular disease, and previous vascular and cardiac surgery.

On 19 March, an orthopaedic senior medical officer suspected the man's left leg had a sudden, severe drop in blood flow and required vascular review. However, the house officer documenting the encounter did not record this suspicion, instead noting a plan for a vascular consult regarding peripheral vascular disease.

Despite nursing staff recording worsening symptoms between 20 and 22 March, the vascular service was not contacted. On 23 March, Mr A was diagnosed with acute limb ischaemia and underwent surgery that afternoon.

How it developed

• Tue 20 Oct, 10:19amHealth NZ has implemented changes including structured long weekend handovers and vascular assessment training for staff.

Where reports differ

• One report notes the man was identified as Mr A, while others refer to him as a man or a patient.

Compiled from reports by NZ Herald, Otago Daily Times, RNZ and Stuff.