Source: Health and Disability Commissioner
The Deputy Health and Disability Commissioner found an over stretched and under resourced emergency department were factors contributing to the death of an elderly woman from hypoxic brain injury (oxygen deprivation).
Carolyn Cooper found Te Whatu Ora – Te Pae Hauora o Ruahine o Tararua MidCentral (formerly MidCentral District Health Board) breached Right 4(1) of the Code of Health and Disability Consumers’ Rights (every consumer has the right to services provided with reasonable care and skill). It also breached Right 4(5) (every consumer has the right to cooperation among providers…).
She also found a registrar breached Right 4(1) of the Code for prescribing medications to the woman without input from senior medical staff.
Ms Cooper said the ED lacked a system to guide staff in their actions when the agitated woman presented to the ED. She found significant deficiencies in the care provided to the woman including inadequate monitoring and poor communication between the different disciplines involved in the woman’s care
The woman (Ms A) fractured her nose following a fall at home. She was transferred to Palmerston North Hospital Emergency Department by ambulance. She had a history of mental health combined with cardio respiratory issues.
Ms A was given a range of sedatives to manage her agitation but went into cardiorespiratory arrest and had to be resuscitated. Following surgery to control her bleeding nose, she was transferred to the intensive care unit but was found to have sustained a brain injury. She was taken off life support four days later and died.
Ms Cooper says the findings highlight the importance of making sure sedation is performed in a monitored area by appropriately skilled staff who are able to intervene when they recognise complications.
“Public hospitals have a duty to provide services of an appropriate standard… Ms A presented to ED with an acute and moderately severe nosebleed following an unwitnessed fall. Her age and history of mental health and cardio respiratory disease meant she was a particularly vulnerable patient who required close monitoring. Unfortunately, despite knowing these factors, the care provided to her was deficient in several respects.”
Te Whatu Ora – Te Pae Hauora o Ruahine o Tararua MidCentral has implemented several changes including updating its policies for procedural sedation and developing guidelines for sedation of agitated patients.
Ms Cooper recommended it provide a written apology to the family of the deceased woman.
Names have been removed from the report to protect privacy of the individual involved in this case. We anticipate that the Commissioner will name DHBs and public hospitals 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. HDC’s naming policy can be found on our website here https://www.hdc.org.nz/decisions/naming-policy/
