How a GP’s illegible referral fed into a fatal outcome

But it wasn’t his bad handwriting that caused the patient’s death

A GP’s illegible referral to a hospital surgeon was the first of a series of missed opportunities that led to amputation of a woman’s foot and ultimately her death, the New Zealand Health and Disability Commissioner has found.


While the GP's practice of hand-written note-keeping departed from accepted standards, the commissioner was mostly critical of the Whanganui District Health Board and two district nurses whose care he said was “suboptimal”.

The nurses, both individually and as a team, failed to measure the woman’s pain objectively and to respond to her deteriorating state,