Source: MIL-OSI Submissions
Source: Health and Disability Commissioner
The need to recognise a patient’s deteriorating condition and provide appropriate intervention was highlighted in a decision published by Health and Disability Commissioner Morag McDowell.
Ms McDowell found a consultant surgeon in breach of the Code of Health and Disability Services Consumers’ Rights (the Code). Her decision emphasises the importance of critical thinking when re-assessing a patient and reviewing the diagnosis and management plan.
A man, aged in his seventies, had a number of health issues. He underwent a colonoscopy at his local district health board (DHB) during which a number of polyps were removed. He presented to hospital the day after the colonoscopy with abdominal pain, and an x-ray suggested his bowel was perforated. The clinicians at the local hospital considered the man was too high risk to be managed at their DHB due to his existing medical conditions and the likely need for intensive care following surgery. Arrangements were made for the man to be transferred to a larger hospital, at another DHB, for further care. Before the transfer, a CT scan was taken that again showed a likely bowel perforation.
On arrival to the larger hospital, the man’s condition was stable. The surgical team made the decision to treat him conservatively, without surgery, as surgery was likely to be difficult and complex due to the man’s existing medical conditions. Over the next two days, the man’s condition deteriorated. When the consultant surgeon reviewed the man during a ward round on the third day, he did not identify any deterioration and so the plan for conservative treatment was maintained. On the fourth day, the man’s condition worsened and he underwent urgent surgery, which showed extensive faecal contamination from a hole in his bowel. Sadly, he died soon after surgery from septicaemia.
With reference to clinical advice, Ms McDowell accepted that the initial decision to trial conservative management of the man on admission to the larger DHB was reasonable, and a continuation of that plan was cautiously appropriate when he was reviewed the next day.
However, Ms McDowell considered that when the consultant surgeon reviewed the man on the third day, there was a missed opportunity to recognise the man’s deterioration and intervene with surgery at that time.
“I acknowledge that the signs of sepsis were subtle and non-typical. However, it is well documented in the clinical notes that in the preceding 24 hours, the man had multiple reviews indicating that he was not well. Based on this, and the expert evidence, a deterioration in the man’s condition is evident,” said Ms McDowell.
Ms McDowell acknowledged that staff did not volunteer any information to the consultant surgeon of any changes in the man’s condition. However, she noted that it was the responsibility of the consultant surgeon during the ward round to elicit relevant information from his more junior colleagues.
Ms McDowell considered the errors that occurred were the result of individual clinical judgement, and did not indicate broader systems or organisation issues at the DHB, and therefore did not find it in breach of the Code. However she was critical of several aspects of the man’s care in relation to the delayed medical review, documentation, escalation of care and communication.
Ms McDowell recommended the consultant surgeon provide a written apology to the family.
Ms McDowell also recommended the larger DHB provide training on documentation to junior staff in the Surgery Department, consider a review of the training provided to junior doctors on escalation following multiple reviews of a patient, and consider developing a guideline for documentation of patient handover. She further recommended it provide an update on the changes made as a result of these events, including the education provided to relevant staff on decision-making and sepsis, and the development of a sepsis programme.
Ms McDowell further recommended the man’s local DHB provide an update on the changes to their procedures made as a result of these events, and the larger DHB upskill and mentor the man’s local DHB’s endoscopy service in polypectomy technique and assessment of polypectomy sites.
This case relates to a complaint made to HDC in 2018. We aim to investigate complaints as promptly as possible, ensuring natural justice and the interests of all the parties involved to provide information, is considered.
Names have been removed from the report to protect privacy of the individuals involved in this case. The DHBs involved in this case have not been named as they were not found to be in breach of the Code.
We anticipate that the Commissioner will name providers found in breach of the Code, unless it would not be in the public interest, or would unfairly compromise the privacy interests of an individual provider or a consumer.
More information for the media and HDC’s naming
policy can be found on our website here.
