The man visited Whanganui Hospital eight times in three months for an ingrown toenail. Photo: LDR / Moana Ellis
A man who went to hospital eight times with an ingrown toenail ended up having his leg amputated.
An investigation by the Deputy Health and Disability Commissioner Dr Vanessa Caldwell found Whanganui District Health Board, now Te Whatu Ora Whanganui, failed to co-ordinate over his care.
The man, in his 60s, visited Whanganui Hospital eight times in three months for an ingrown toenail between June and August 2018.
His toe was amputated to stop the spread of infection, but six days later, his leg had to be amputated at a different hospital, which the report does not name.
The man, referred to in the report as Mr A, made a complaint to the commissioner about his experience.
Dr Caldwell found despite multiple visits and chronic conditions, a care plan directed by a senior staff member was not put in place - instead, each visit was managed in isolation.
"A hospital system would be expected to operate in such a way that a patient who has attended numerous times with the same issue would be afforded continuity of services, for example by having a dedicated team assigned to oversee, monitor and plan the patient's care," she said.
One of the doctors involved told the commissioner the main factor which contributed to Mr A's amputation was poor circulation in his legs due to peripheral vascular disease and diabetes.
Te Whatu Ora Whanganui has since established a high-risk foot clinic to focus on education, diagnosis and care plan development, treatment and onward referral.
According to the report, the clinicians involved had reflected on the care they provided, and in future would have a lower threshold for vascular imaging.
