Health NZ found to have breached care standards for tetraplegic patient at North Shore Hospital

After a scooter fall, a 69-year-old man with ankylosing spondylitis presented to North Shore Hospital reporting head pain and thoracic discomfort but no weakness. Clinical notes indicate he was log-rolled onto a stretcher, yet the patient and his family say he moved himself, and a later review found the log-roll unlikely. While awaiting a CT scan, he noted numbness in his right ring finger, which was not reassessed adequately.

He later positioned himself on the CT table, experienced severe neck pain, and the scan revealed a C6-7 fracture-dislocation, resulting in tetraplegia. The Health and Disability Commissioner found Health New Zealand breached the man's rights by omitting a comprehensive neurological exam and permitting independent movement onto the scanner, despite his risk factors. The agency affirmed the CT was necessary but highlighted the care deficiencies. Health New Zealand has since instituted mandatory spinal-precaution training and specific protocols for patients with fixed-spine deformities, and it must issue a written apology to the patient and his family.