The Nelson Marlborough District Health Board has been found to be in breach of the health code after a man died from a heart attack while in a mental health facility, a day after he was declared medically fit to leave hospital.
Health and disability commissioner Anthony Hill found the Nelson Marlborough DHB to have breached the code after the severity of the damage to his heart was not recognised when he was in hospital.
He had a family history of heart attacks, and went to the emergency department at hospital for a mental health assessment. He returned to the emergency department the next day after self-harming.
He then had a cardiac event, and was transferred to the intensive care unit at a different hospital.
The man’s condition was reviewed by a cardiologist and he was declared medically fit to be discharged. He was then transferred to a mental health facility where he was to be observed every 10 minutes.
The next morning the man was found dead in his room, and the coroner found the cause of death to be an irregular heartbeat caused by a recent heart attack.
The mental health facility confirmed that the 10-minute observations were adhered to overnight.
Hill found the man’s discharge from the intensive care unit was inappropriate,and that the severity of damage to the man’s heart was not recognised.
Hill recommended that the Nelson Marlborough DHB implement a system to ensure a patient’s treating clinician is alerted urgently when cardiac results are abnormally high, audit the rate of cross-referencing information about overnight observations of patients, review policies regarding the management of at-risk patients, provide staff training and apologise to the man’s family.
-Story by NZ Herald