A man arrived at hospital with a sore elbow. He died five days later after having his leg amputated

A man who injured his elbow in a fall at home had his leg amputated in hospital five days later.

However, hours after having his lower leg removed above the knee, the man, who had complex health challenges, died.

Now the country’s health services watchdog has found individual staff carried some responsibility for what happened, but overall, Health NZ failed to ensure timely assessment and diagnosis.

In findings released today, Deputy Health and Disability Commissioner Vanessa Caldwell said the delays were the result of a “series of failings involving multiple staff”, including inadequate documentation and communication of Senior Medical Officer concerns.

The matter was referred to the HDC by the Coroner’s Office after concerns were raised about the care provided to the man in the hospital operated by Health New Zealand/Te Whatu Ora Southern in March 2021.

The man arrived at Dunedin Hospital on March 18 with an elbow injury after a fall at home.

Dr Caldwell said he had an extensive medical history, including diabetes and peripheral vascular disease, and had undergone vascular and cardiac surgery.

He had surgery on his elbow and remained in hospital on the orthopaedic ward to await further surgery.

The next morning, an orthopaedic house officer reviewed the man because of concerns of numbness in his left leg and pain in the sole of his left foot.

The man reported the problems as “longstanding” but the pain had increased slightly since the fall.

The doctor concluded it was likely a chronic issue and unlikely related to the fall.

The man was seen that afternoon by an orthopaedic senior medical officer with the house officer in attendance.

Unable to stand

A physiotherapist had alerted the more senior doctor that the man was unable to stand.

The senior doctor recalled that after examining the patient’s legs, he felt that the left one had a sudden, severe drop in blood flow and needed to be reviewed by the vascular service.

However, the house officer documenting for the senior doctor did not record his suspicion of Acute Limb Ischaemia [ALI].

Caldwell said the documented plan instead was for “vascular consult about PVD [peripheral vascular disease]”.

She said information the house officer provided to the vascular registrar during a telephone consult had not been documented.

Caldwell said the registrar declined to arrange a review.

The house officer documented that because there were “no new acute issues”, the vascular service would not “come and see”.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell said it was unacceptable that the patient was not reviewed by the vascular service until four days after a senior doctor identified his leg appeared acutely ischaemic. Photo / James Gilberd Photography Ltd

The man was assigned an outpatient referral unless things worsened or progressed.

On March 20, nursing staff recorded the man’s left leg was “cool, pale and numb” but that was not new for him.

Over the following two days they documented progressively worsening concerns about the man’s left leg.

By March 21 he was experiencing spasms, pain and that his left leg was “lighter and paler than his right leg”.

Nursing staff arranged a review by the on-call house officer who said the vascular service would only see the man if his symptoms were “worsening”.

On March 22, nurses said he was unable to move his left leg and was in severe pain requiring increased pain medication.

The vascular service was not contacted, Caldwell said.

The next day, during the orthopaedic ward round, the man had no movement or sensation in his left leg.

He was diagnosed with acute limb ischaemia, requiring amputation of his left leg above the knee.

Caldwell said he experienced further complications after the surgery and died in hospital a short time later.

Coroner report identified delays in referral

Expert medical advice to the coroner identified delays in referring the man to vascular services early on.

There were indications that the circulation in the man’s left leg was “seriously compromised” to the extent that the vascular service should have been called at that point, Caldwell found.

She said Health NZ had a duty to ensure that services were provided to the man with reasonable care and skill, but that had not happened.

“It is unacceptable that [he] was not reviewed by the vascular service until four days after [a doctor] identified that his leg appeared acutely ischaemic,” she said.

She acknowledged the man’s history of chronic PVD, which made assessment of his leg symptoms difficult.

However, the possibility of a more serious situation was identified the day after he arrived at hospital and nursing staff “clearly recognised his deteriorating condition”.

Health NZ Southern had since made changes, including that nursing team leaders and managers now had more oversight in the escalation process.

Junior doctors and appropriate nursing staff were now required to undertake training in basic vascular assessments.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.