Woman dies after nurse incorrectly classifies disease


Pamphlets from the Office of the Health and Disability Commissioner, advising people of their rights


Photo: Supplied/ Office of the Health and Disability Commissioner

The Health and Disability Commissioner has criticised Kaitaia Hospital for its insufficient treatment of a woman who died from a diabetes-related infection.

The woman, named Ms B in the report, developed Type 2 diabetes at age 23 and was in her thirties when she died.

Her toe had to be amputated after she developed sepsis in early 2017, followed by a below-the-knee amputation just a few days later.

She died from an infection in her groin after about six weeks.

Deputy Commissioner Rose Wall found that a nurse had incorrectly classified the woman’s disease and referred her to the podiatry service instead of the diabetes clinic.

But Wall acknowledged that the nurse was working within a “confusing” system with little guidance.

Wall said the podiatry service Ms B was referred to did not provide adequate processes, but noted the service had stopped operating in March 2022.

She said the breach of the Health and Disability Services Consumers’ Rights Code was ultimately the responsibility of Health NZ.

“Health NZ Te Tai Tokerau was the group provider with overall responsibility for ensuring that the woman received timely intervention to try to avert the profound difficulties she ultimately experienced,” Wall said in a statement.

She recommended that Health NZ apologise to Ms B’s family within three weeks.

Wall said Health NZ had made a number of changes to its processes since Ms B’s death in 2017 which had improved the standard of care for patients with diabetes.



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