An autopsy showed the cause of the man's death was "severe meningoencephalitis with features most in keeping with rheumatoid meningoencephalitis". Photo: 123RF
A man died from inflammation of his brain and spinal cord after being misdiagnosed with concussion and mental health issues.
The Health and Disability Commissioner found clinicians breached the man's rights.
In 2019 the man, who was in his 50s, was found in an agitated state and having seizures on the beach after he had been surfing, and was believed to have been concussed.
The man, referred to in the commissioner's report as Mr A, was taken to hospital by ambulance, and seen by a neurologist.
The neurologist said it appeared the seizures were due to the concussion, and gave the man a discharge plan calling for an electroencephalogram (EEG) to assess for epilepsy, and for him to see a neurologist as an outpatient once the EEG was done.
The man's GP filed an ACC treatment injury for concussion and referred him to a concussion rehabilitation service.
During the next six months, the man showed a range of complex symptoms, such as headaches, photophobia, nausea, and changes in mood, and repeatedly sought medical help from multiple clinicians, deputy commissioner Dr Vanessa Caldwell said.
The man died six months after the initial incident, and an autopsy showed the cause of death was "severe meningoencephalitis with features most in keeping with rheumatoid meningoencephalitis".
The man had been diagnosed with rheumatoid arthritis in 2018.
The requested EEG was never done, with the medical centre saying it thought Health NZ was arranging for the EEG, Caldwell said.
Health NZ did not arrange for the outpatient neurology appointment or the EEG, and did nothing to check why the appointments had not happened.
HNZ said neither of these tasks were completed due to administration issues.
The concussion rehab service said it had trouble engaging and getting in touch with Mr A.
The service's documentation and communication with the man's medical centre was poor, Caldwell said.
Over the six months between the initial incidents and his death the man started showing a range of unusual symptoms.
This included mood swings, amnesia, headaches, urinary incontinence, balance issues, impulsive and abusive behaviour, and discoordination of thoughts and actions.
The man's wife raised concerns about his behavioural changes and he was assessed by Mental Health and Addiction Services.
The report outlined an incident in which a GP and a registered nurse visited the man at home.
The man's wife said the registered nurse berated and belittled Mr A, asking him to "sort himself out".
This was repeated over and over and the nurse was backed up by the GP, the wife told the commissioner.
Mrs A said the GP advised her to ignore Mr A's behaviour as he was "putting it all on and only ramping up his manipulation".
The GP acknowledged saying Mr A's behaviour seemed to be manipulative, and said that was based on previous observations of Mr A and was based on many sources.
The GP said he did not consider the communication disrespectful or belittling, but expressed sincere apologies if it was perceived in this way.
Caldwell said Mr A's presentation was unusual for rheumatoid meningoencephalitis.
Rheumatoid meningoencephalitis does have a poor prognosis, so even if a more timely diagnosis had been made the outcome may not have changed, she said.
"However, the fact remains that several systems failures cumulatively led to Mr A receiving a poor standard of care," Caldwell said.
"These failures deprived Mr A of the opportunity for earlier investigations and interventions, an understanding of what was causing his symptoms, and an opportunity for him and his whānau to prepare for the prognosis."
A number of recommendations were made for HNZ, the medical centre and the rehabilitation centre.
HNZ was recommended to complete a random audit of discharge letters and determine if they had been followed through, and audits of mental health inpatients to look at whether organic causes were ruled out before psychiatric diagnosis was considered.
The medical centre was told to write a formal apology to Mr A's family and to improve its communication with the rehabilitation service provider.
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