Health News – Woman who developed sepsis did not receive care of acceptable standard says HDC

Deputy Health and Disability Commissioner, Deborah James, has found Southern District Health Board did not provide services of an appropriate standard to a woman who developed sepsis following surgery at Dunedin hospital.

Deborah James issued the decision in relation to the care provided to a woman who suffered a fractured femur in a skiing accident. The woman underwent surgery to repair the fracture but developed sepsis the day before she was scheduled to return to her home country.

Blood tests and blood cultures were ordered, but no action was taken on the abnormal results. It took over ten hours from when the blood tests were requested for treatment to be provided to the woman.

Deborah James found Southern District Health Board breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights – the right to have services provided with reasonable care and skill. She says the case highlighted the importance of recognising and identifying sepsis, and taking the appropriate actions when a patient’s condition deteriorates.

Deborah James considered that clinical staff should have postponed the planned repatriation earlier than eventuated. “Staff failed to obtain the full clinical picture….did not appreciate the risks involved in proceeding with the repatriation….and did not take the appropriate actions, as required by the Deteriorating Patient Early Warning Score (EWS) Escalation Pathway Flowchart, when the woman’s condition deteriorated and her EWS increased”.

The woman also raised concerns about the standard of clinical documentation on her case. Southern District Health Board accepted that the wording used in the clinical documentation was unprofessional.

Southern District Health Board advised HDC that it has made a number of changes since these events occurred. In addition to those changes, Deborah James recommended Southern District Health Board provide a formal written apology to the woman; and:

– develop, and implement, guidelines for the identification of sepsis, and for assessing and managing patients who are clinically symptomatic of sepsis;

– audit the management of EWS for ten consecutive patients admitted to the ICU for sepsis and present the findings to the Clinical Directors meeting and the Deteriorating Patient Recognition and Response Committee;

– provide all nursing staff who were involved in the woman’s care with training on documentation, and undertake audits of their documentation; and

– use this report as a basis for both nursing and medical staff learning at Southern District Health Board.