Repeated failures by hospital doctors ended in patient's death

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Repeated failures by hospital doctors ended in patient's death
Repeated failures by hospital doctors ended in patient's death

A woman who died from a pulmonary embolism should have been given potentially life-saving treatment hours before her death in a public hospital, a patient watchdog has found.

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The Health and Disability Commissioner has criticised the care given to the woman by Southern District Health Board in 2019, and taken the extra step of referring the DHB to the Director of Proceedings where it could face further disciplinary action.

Health and Disability Commissioner Morag McDowell found the DHB in breach of the Code of Health and Disability Services Consumers’ Rights for failures by numerous staff across the emergency department (ED) and respiratory teams to provide services with reasonable skill and care.

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In her report released today, McDowell said the patient, a woman in her 60s known as Mrs A, was sent to the hospital emergency department by her GP where it was confirmed by CT scan she had a pulmonary embolism – a blood clot blocking an artery in her lung.

During her investigation the commissioner found there were at least three times the woman could have been given thrombolysis – a treatment used to dissolve blood clots.

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Instead, and despite a medical registrar describing the embolism as massive, with significant effect on the cardiovascular system and the patient having an “intermediate to high risk” of death, doctors adopted a “wait and see” approach.

A medical registrar and respiratory consultant planned to admit the woman to the coronary care unit but without a free bed there she remained in the ED, where who was in charge of her care became confused.

Despite Mrs A’s vital signs indicating she was in shock three times in 20 minutes, and her systolic blood pressure dropping to 90mm Hg, junior staff did not escalate her care to a senior doctor, and she was only treated with intravenous fluids and blood-thinning medication.

At one point her blood pressure was fluctuating so much she was moved to the resuscitation bay, and at 9pm and 10.21pm her systolic blood pressure dropped to below 90 twice, where thrombolysis is recommended.

The commissioner found there was a good case for thrombolysis as early as 7pm. She also found it difficult to determine who reviewed the patient at several stages because there was no documentation in the clinical notes.

Mrs A was finally admitted to the coronary care unit late that night, where a house officer would later say although he remembered the night in question as a busy one, he could not recall any detail about a review of the woman’s condition on arrival.

From his point of view a number of patients were more unwell and potentially of more concern than Mrs A.

Another doctor reviewed Mrs A at 6.30am and would later apologise to the family for not speaking to a senior doctor on-call over the case.

At 7.10am the woman’s daughter pressed an emergency bell when her mother lost consciousness but attempts to resucitate Mrs A were unsuccessful and she died at 7.50am.

Repeated failures by hospital doctors ended in patient's death

Health and Disability Commissioner Morag McDowell has criticised Southern DHB staff over the death of a patient who didn't receive potentially life-saving treatment. Photo / Dean Purcell

The on-call respiratory consultant was not contacted until after Mrs A died but told the HDC he should have been.

This was at odds with a statement from the clinical team coordinator who said it would be relatively unusual for a consultant to come in at night.

“It is concerning that staff considered it uncommon for an on-call consultant to be contacted at the public hospital overnight, especially when Mrs A’s early warning signs [EWS] scores clearly indicated that she was not improving with the plan in place, and SDHB’s EWS policy stipulated that senior medical officer escalation was warranted on multiple occasions,” McDowell said.

However Southern DHB did not accept the case was “indicative of a concerning pattern among junior staff not to involve senior clinicians” and that a lack of escalation on the night was the result of a series of clinical decisions, not a systemic issue.

It asked the commissioner to reconsider her referral to the Director of Proceedings, where further action can be taken.

But McDowell said she considered there were multiple missed opportunities by staff to escalate Mrs A’s deterioration to the responsible senior doctor, and to consider thrombolysis as a potential treatment and that they failed to exercise sound clinical judgment.

She considered the failures indicated a pattern of poor care for the patient, as well as a culture of non-compliance with Southern DHB’s policies and procedures.

Poor documentation prevented her from attributing responsibility to individuals and she found it highly concerning that the DHB was unable to identify with any certainty the registrars responsible for some of the clinical decision-making.

The commissioner made an adverse comment against two of the doctors involved.

The daughter said she found herself in a difficult position as a trained healthcare professional having to advocate for her mother and told the HDC “good acute clinical care should never be dependent on the advocacy role of a patient’s relatives”.

McDowell made a number of recommendations to the DHB including that it consider whether its guidelines for thrombolysis in patients with acute pulmonary embolism could be strengthened to include specific reference to indicators of shock, and that it promote awareness or develop a process for nurses to contact senior doctors directly in appropriate circumstances.

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