The Deputy Health and Disability Commissioner has found Te Whatu Ora Southern and a registrar breached a man's rights under the Code of Health and Disability Services Consumers' Rights, after he died of a brain haemorrhage.

The man had an unwitnessed fall at his care home and was taken to Southland Hospital emergency department.

A yellow envelope containing patient information was misplaced which meant that hospital staff who were treating the man were not aware that he was on anticoagulants, commonly known as blood thinners.

The man had his initial observations taken by a registered nurse about six hours after his arrival at hospital. He was first seen by the registrar around nine hours after his arrival.

The registrar noted it was usual practice for her to review the information in the yellow envelope but there was not one and the registrar did not order a CT scan because she was not aware he was on anticoagulants.

The man was kept under observation and was discharged back to the care home the next day.

He became increasingly ill and was taken back to Southland Hospital where a CT showed he had experienced an intracranial haemorrhage and he later died.

Deborah James said Health NZ breached the Code by not providing services with reasonable care and skill.

"Health NZ did not have a clear or well understood process in place for ambulance staff to hand over the yellow envelope when there were no available beds in ED, resulting in the man's yellow envelope being misplaced," she said.

She added that the man was not assessed for initial observations until around six hours after his arrival and that several clinicians had failed to identify he was on warfarin.

James said those factors combined meant Health NZ did not provide the appropriate standard of care.

She also noted that due to the man's age, fragility and because he had suffered a head injury, a CT scan should have been completed, regardless of whether or not he was on anticoagulants.

James recommended both parties formally apologise to the man's family and that Health NZ standardise its process for yellow envelopes to cover when there are no beds available.

Te Whatu Ora has since increased the number of nurses on at night shift and made sure there is always a medical imaging technologist on site to take scans.

The registrar has also made a number of changes.

Published by permission