Source: Radio New Zealand
The prisoner was seen by multiple nurses in the six days she was ill before being taken to hospital, but most basic clinical observations were not recorded in that time. (File photo) RNZ/ Finn Blackwell
A prisoner with a burst appendix was told it was a stomach bug, and waited six days to be admitted to hospital for surgery.
The Health and Disability Commissioner said multiple registered nurses saw the woman, but their clinical impression was that of a viral infection.
On her admission to hospital on 5 July, 2022, she was diagnosed with a burst appendix, and the next day she underwent an operation to remove her appendix, drain a pelvic abscess, and remove a section of her large intestine.
Her symptoms were first flagged after a standard morning medication round, when two nurses noted that the woman, who the report calls Ms A, had been vomiting for the past three days and unable to keep food down.
Ms A told the commissioner investigating her case that a nurse told her it was a stomach bug, and when her symptoms persisted at the next appointment, she was told to “ride it out”.
The prison has denied clinical staff said this. It explained the woman’s treatment was focused on managing nausea and vomiting, and maintaining hydration, as nurse assessments indicated a viral illness and an absence of any red flag symptoms.
The woman was seen by multiple nurses during the next six days for nausea, vomiting, and diarrhoea, but there was no record of observations like temperature, blood pressure, or pulse, no abdominal examinations, and no description of bowel movements taken at these assessments.
There was also no evidence her fluids were monitored, despite the vomiting, and no clear record of the effect of pain medication provided.
She was eventually referred to the local hospital by a medical officer, following blood tests on 5 July.
She spent nine days in hospital, and was discharged on 14 July. She complained to the Health and Disability Commissioner the following month, on 22 August.
Commissioner Vanessa Caldwell found the Department of Corrections had breached the Code of Health and Disability Services Consumers’ Rights by failing to provide appropriate care to Ms A, and to escalate her care in light of her symptoms and multiple presentations.
Department of Corrections accepts the care was below standard, blames staff shortages and high turnover
According to the HDC report, the Department of Corrections accepted the nursing assessments and documentation did not meet professional standards – or the department’s own expectations.
However, it explained its health team was experiencing high volumes of staff vacancies, staff turnover, and unplanned absences at the time of these events.
The prison, which is not named in the report, also had no permanent health centre manager nor access to a clinical quality assurance advisor at the
time, it said.
Ms A said she was in a vulnerable and dependent state, and the clinical staff did not do enough to escalate her care. She said the consequences of these events have greatly affected her, and she has since undergone a second surgery.
Changes since the incident
The prison told HDC the following changes had been made since the incident:
Commissioner also recommends a written apology
The commissioner said the prison should write an apology to Ms A, to be sent to HDC within three weeks for forwarding.
When Corrections was approached for further comment, Juanita Ryan, deputy chief executive Pae Ora, said she would like to reiterate the department’s apologies to Ms A.
“The medical care Ms A received fell short of what is rightly expected of us. It is critical that while someone is in our custody, we support and improve their health, ensure their physical safety, and treat them with dignity and respect. In this instance we did not provide adequate healthcare for Ms A and for this we are truly sorry. We have apologised to Ms A directly.”
She said they had done or were on track with a number of other recommendations made by the commissioner – including providing copies of relevant guidance documents and audit findings.
Corrections now also required evidence that all staff at the prison had completed the Graduate Certificate in Nursing: Rural Assessment of the Deteriorating Patient at Ara Institute of Canterbury, she said, and a new online training module on pain management was on track to be completed by the end of March.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
