The Taranaki District Health Board has been found in breach of the Code of Health and Disability Services Consumers' Rights after an elderly man died 40 minutes after being discharged from Taranaki Base Hospital in 2021.
The man, in his eighties, was treated at the hospital for five days for abdominal pain and worsening chronic obstructive pulmonary disease - a common lung disease that causes breathing problems.
Although he was "improving medically" on the day he was discharged, he was still experiencing shortness of breath, the Aged Care Commissioner's report said.
He was given prednisone and a "back pocket" prescription for antibiotics in case his symptoms flared up again and told to see his GP or visit the emergency department if his shortness of breath worsened.
The man's daughter said her father was unable to walk unassisted when he left the hospital and needed help from members of the public to move him from a wheelchair to the car.
She then struggled to get him up the three flights of stairs into his home, and he died about five minutes after arriving.
Commissioner Carolyn Cooper found the Taranaki District Health Board (now Health New Zealand Te Whatu Ora Taranaki) breached the patients' code by not providing services of an appropriate standard.
The discharge was "unsafe" due to "a lack of critical thinking and communication", she said.
Hospital staff did not record key information about the man's functional ability and what post-discharge advice and support was provided.
"The discharge checklist includes important information such as whether the patient is likely to have any difficulties with self-care on discharge… whether they are concerned about returning home, the level of support services they currently receive, and their arrangements for transport on discharge. None of this information was included."
Cooper said the man's safe discharge "depended on all members of the multidisciplinary team agreeing that he was ready for discharge, which did not occur".
There was also no evidence recorded about him receiving physical or occupational therapy during his hospital stay, and there were no referrals made for him to get this treatment post-discharge.
The report noted that since the man's death, "Health NZ Taranaki has trained a senior ward registered nurse to undertake the role of complex discharge coordinator to ensure this service is always available on the acute medical ward during work hours".
The commissioner made several recommendations, including that Health NZ formally apologise to the man's family, audit the completion of admission documentation for the past six months, update training on discharge planning, and review and update its discharge planning procedure.
