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Decision 08HDC10486
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Names have been removed (except IHC, Hutt Valley DHB/Hutt
Hospital and the experts who advised on this case) to protect
privacy. Identifying letters are assigned in alphabetical order and
bear no relationship to the person's actual name.
Hutt Valley District Health Board
A Report by the Deputy Health and Disability Commissioner
Overview
Mr A was a 35-year-old man with cerebral palsy and an
intellectual impairment. Just before 9am in early 2008, Mr A
presented at Hutt Hospital's Emergency Department (ED) with
abdominal discomfort. He was accompanied by a community services
worker, Ms D. Just after midday, Mr A was reviewed by an ED medical
officer, who made a provisional diagnosis of constipation and
referred him for a surgical review. Mr A was eventually seen at
9.30pm by a surgical registrar, who arranged for him to have an
abdominal CT scan. This showed mildly dilated loops of the small
bowel. In the early hours of the following day, Mr A was
transferred to a surgical ward, and later that morning he had
surgery.[1]
Two days later, Mr A had a further procedure to rule out the
possibility of a bile leak. Over the next two days his condition
fluctuated. Three days later, Mr A developed respiratory distress
and stopped breathing. Attempts to resuscitate him were
unsuccessful and he died. The post-mortem reported Mr A's cause of
death as bronchopneumonia[2] as a consequence
of gall bladder disease and gallstones which had necessitated
surgical intervention.
This report considers the adequacy of the care provided to Mr A
by Hutt Valley District Health Board.
Complaint
On 26 June 2008, the Health and Disability Commissioner received
a complaint from an IHC advocate, Mr B, on behalf of IHC, about the
services provided to Mr A by Hutt Hospital.[3]
The following issue was identified for investigation:
- The appropriateness of the care provided by Hutt Valley
District Health Board to Mr A over the period of a week in early
2008.
An investigation was commenced on 23 September 2008. The
investigation was delegated to Tania Thomas, Deputy Health and
Disability Commissioner, and her opinion has been formed in
accordance with the power delegated to her by the Commissioner.
Independent expert advice was obtained from emergency specialist
Dr Garry Clearwater (Appendix 2) and surgical expert Dr Andrew
Connolly (Appendix 3).
Parties involved
Mr
A (dec),
Consumer
Mr
B
Complainant / IHC Advocate
Hutt Valley District Health
Board Provider
Dr
C
Consultant General Surgeon
Ms
D IHC
Community Services
Worker
Ms
E IHC
Community Services
Manager
Mr
F Registered
Nurse (ED)
Dr
G ED
Medical Officer
Dr
H Surgical
Registrar
Ms
I Registered
Nurse (ED)
Ms
J Registered
Nurse (Agency)
Ms
K IHC
Community Services
Worker
Ms
M Registered
Nurse (ED)
Dr
L ED
Consultant
Dr
O Anaesthetic
Registrar
Dr
N Anaesthetic
Consultant
Mr
P IHC
Service Manager
Dr
Q Surgical
Registrar
Mr
R IHC
Acting Community Services
Manager
Information gathered during investigation
Background
Mr A was a 35-year-old man who was diagnosed with cerebral palsy
when he was several weeks old. He also had an intellectual
impairment. At the age of 20, Mr A had a cerebrovascular accident,
which left him with right-sided weakness and moderately high
support needs. In 1996, Mr A moved into the care of IHC. Mr A had
no next of kin or welfare guardian.
Since 2004, Mr A had been living in Lower Hutt with four
flatmates. They were supported by IHC staff. Community services
workers assisted Mr A on a daily basis with personal care and other
activities. Mr A's verbal communication was limited but he was
fully aware of what was happening around him. Staff who knew him
well were, to some extent, able to interpret his non-verbal
communication and behaviour patterns.
In August 2006, Mr A was placed on a waiting list for a
cholecystectomy (surgical removal of the gall bladder) after an
abdominal ultrasound confirmed gallstones. In May 2007, he was
reviewed at Hutt Hospital by a consultant surgeon, Dr C. Dr C
discussed Mr A's condition with her colleagues and with Mr A's GP.
As there were no symptoms of gall bladder disease, the decision was
made to take Mr A's name off the list for surgery. At this time, Dr
C also discussed with Mr A's GP the need for "someone with Power of
Attorney" to be appointed for Mr A.
Sunday, early 2008
On a Sunday in early 2008, community services worker Ms D went
to get Mr A out of bed. She found him wet with sweat, with a hard
and enlarged stomach, and reluctant to get up. Ms D contacted an
after-hours medical centre just before 8.30am and, on their advice,
called for an ambulance. She also contacted an IHC community
services manager, Ms E. Ms D accompanied Mr A in the ambulance and
Ms E joined them shortly after their arrival at Hutt Hospital, at
8.50am. Mr A was registered by an ED receptionist at 9.04am. He was
triaged at 9.10am as category 3, using the Australasian triage
scale.[4]
Registered nurse (RN) Mr F was allocated as Mr A's primary
nurse. An initial set of observations was taken and it was noted
that Mr A may not have had a bowel motion for four days. However,
Ms D advised that she did not think he was constipated. RN Mr F
reported that he performed visual and verbal checks at
approximately 30-minute intervals throughout the morning, but did
not document these.
Ms D reported that Mr A was indicating, using verbal signs, that
he was in pain. Another IHC community services worker, Ms K, stated
that just before midday a nurse asked about Mr A's usual pain
relief.[5] After checking with a colleague, Ms
K advised the nurse that this was liquid paracetamol. However, no
pain relief was provided at this time. No clinical observations
were recorded between 9.10am and midday. The observations taken by
RN Mr F at midday were satisfactory.[6]
Mr A was seen by an ED medical officer, Dr G, at 12.15pm.[7] Dr G ordered blood
tests and an abdominal X-ray. He discussed his findings over the
telephone with a surgical registrar, Dr H, who said that he would
review Mr A. The time of this call is not recorded but it appears
that it was early afternoon. At this stage Dr G recorded a
provisional diagnosis of habitual constipation, and noted that Dr H
would review "[o]r could consider [discharge] back to supervised
residence with laxative and see [as needed] (if inflammatory
markers are [normal])".
Ms K stated that at 2.45pm, she asked a nurse whether Mr A
should take his usual reflux medication, domperidone. She also
requested pain relief for Mr A. Ms K understood that the nurse went
to check, but said she did not return with an answer.
At 3.00pm, RN Mr F handed over the nursing care of Mr A to RN Ms
M. RN Ms M documented that Mr A was not acutely distressed, his
clinical observations were satisfactory, and he was awaiting a
surgical review. Ms D stated that she made a request for pain
relief for Mr A at 3.30pm (when she returned to the hospital), but
there is no record of any having been administered. Around 4.30pm
Ms D recalled a nurse speaking with her about Mr A needing an enema
for his constipation. Ms D expressed doubt that constipation was
causing Mr A's pain and suggested that the enema be performed at
the hospital so that he could be reassessed afterwards.
Soon after 4pm, Dr G handed over the medical care of Mr A to an
ED consultant, Dr L. At 5.30pm, Dr L reviewed the abdominal X-rays
and Mr A. She was concerned about a possible bowel obstruction and
recorded that Mr A appeared dry and uncomfortable. Dr L inserted an
intravenous cannula (IVC), and recorded a plan for further blood
tests, intravenous fluids and a surgical review. Dr L is certain
that there would have been a further attempt to page the surgical
registrar after she had seen Mr A. There is an entry in the nursing
notes to indicate this was done, although the time of the call was
not noted.
Ms D stated that at 6pm, she again requested pain relief. She
also advised a nurse that Mr A was vomiting but holding the vomitus
in his mouth and then swallowing it.
Ms D provided staff with a page of written advice on caring for
Mr A, including guidance on recognising both specific and general
pain; how stressed he was likely to be in hospital; that he would
try to remove his intravenous line and catheters (and how to deal
with this); how he could be offered fluids; how to assist his
mobility; and how to tell when he was happy. Ms D recalls writing
this in ED and giving it to RN Ms M, although the DHB stated that
it was produced after Mr A transferred to a surgical ward and was
not available to ED staff.
At 7.40pm an intravenous infusion of normal saline was charted
and commenced. Shortly after this, morphine (2mg) was charted and
administered. Mr A's temperature rose from 36°C at 6.20pm to 38.3°C
at 10pm. His blood pressure and pulse rates were checked at 6.20pm,
7.45pm, 8pm, 10pm and 10.16pm, and these also showed increases.[8] RN Ms M recorded
that Mr A had made frequent attempts to pull out his IVC and that
they had been unable to get a uridome[9] to
stay on.
Mr A was seen by Dr H at about 9.30pm. Dr H subsequently said
(to the ED nurse manager) that he found Mr A's condition worse than
he had inferred from the information given to him. Dr H arranged
for an abdominal CT scan to confirm his provisional diagnosis of
possible infection. The results of the scan were consistent with a
possible small bowel obstruction. Dr H discussed the findings with
Dr C, and documented a medical plan for intravenous antibiotics,
rehydration, insertion of an indwelling catheter (IDC), a
nasogastric tube, and TED stockings.[10] Mr A
was to be admitted under the surgical team and reviewed by a
registrar in two hours' time, with a view to a possible laparotomy
overnight.
Ms E recalled that Dr H spoke to her about the possible
complications associated with surgery. She contacted the IHC area
manager, Mr P. Mr P stated that he spoke with a nurse about Right 7
of the Code of Health and Disability Services Consumers' Rights
(the Code),[11] although no ED staff member
recalls this.
At about 11.30pm, IHC staff (Ms D and Ms E were present) recall
that a nurse in a green uniform (thought to be RN Ms I) came in to
insert a nasogastric tube and to catheterise Mr A. According to IHC
staff, the nurse inserted the catheter fully but removed it after
failing to get any drainage. This happened three times, and she
then sought the assistance of another nurse (in a white uniform),
RN Ms J. RN Ms J retracted Mr A's foreskin and found that the
catheter was coiled around the glans under the foreskin. She then
inserted the same catheter successfully. By this time, Mr A
appeared to be in considerable pain.
RN Ms I recalls that she asked another nurse to perform the
nasogastric insertion and catheterisation, as she was not able to
perform these procedures.[12]
Monday
Although there is no clinical record to indicate that Mr A was
reviewed two hours after Dr H's 9.30pm assessment, Ms D and Ms E
noted that Dr H returned at 12.15am and explained that Mr A
required fluid resuscitation and that if he responded well to this,
surgery would wait until morning.
Mr A was transferred to a surgical ward at about 1.30am. There
is a full record of nursing care provided by staff looking after Mr
A for the rest of the night, including regular observations. A
nurse aid stayed with Mr A from about 3am, when Ms D and Ms E
left.
Mr A was seen by a surgical registrar, Dr Q, at 2.30am. Dr Q
recorded a plan for continued fluid resuscitation and to review in
1-2 hours' time. He saw Mr A again at 4.15am and updated the
medical plan. This included hourly observations, continued fluids
and analgesia, and follow-up with regard to surgery in the
morning.
At 7.45am Mr A was seen by Dr C. She confirmed the impression of
a subacute bowel obstruction and the need for surgery. Dr C
recorded in the progress notes that IHC management staff had
confirmed that Mr A had no power of attorney, legal guardian or
person able to consent to medical treatment. Dr C discussed the
situation with the Clinical Head of Department of Surgery and the
Chief Medical Advisor. They agreed that as Mr A's condition was now
life-threatening, it was appropriate to proceed with surgery. This
was discussed with the IHC staff present. Dr C arranged operating
time for later that morning, which entailed negotiating with
another surgeon to cancel the booking of another patient, who had
been scheduled for elective surgery.
Hutt Valley District Health Board (the DHB) explained that, once
Dr C confirmed that surgery was required that morning, Mr A
proceeded to surgery as soon as an operating theatre could be made
available. Dr C stated that while Mr A's disability made clinical
assessment of his medical condition more difficult than usual and
increased the risk of him developing complications, it did not mean
that surgical treatment was delayed.
Mr A was taken to theatre; surgery commenced at 11.43am and was
completed at 1.05pm. The operation notes indicate that there was no
apparent small bowel obstruction but the gall bladder was inflamed
with an impacted stone in the neck. Mr A's gall bladder and
appendix were removed. The pathology report subsequently confirmed
acute appendicitis.
Mr A returned to the ward at 4.15pm. A nasogastric tube was
sutured to his nasal septum[13] to ensure it
remained in place. Ms D stated that she had to ask the anaesthetist
to explain to Mr A what had occurred during the surgery. The
anaesthetist explained that the surgeon had removed his gallbladder
and his appendix "just in case" he ever got appendicitis in the
future.
Post-surgery
Following surgery, Mr A was seen regularly by the Acute Pain
Management Service, the Surgical Team, critical care outreach
nurses and a physiotherapist.
On Wednesday, two days later, Mr A had an Endoscopic Retrograde
Cholangiopancreatogram[14] (ERCP) due to
concern that there might have been a bile leak in the gall bladder
bed. No leak was found. Later that day, Mr A developed a
temperature and increased respiratory and heart rates. Possible
atelectasis (collapse of all or part of the lung) was noted and IV
antibiotics were prescribed.
By the following morning, Mr A had developed a "wet" cough, and
chest physiotherapy was commenced. Following the operation, pain
had been managed by way of an epidural. Later that day, the
epidural was discontinued and the nasogastric tube removed. Mr A
began having sips of water. He had some reflux, and his pulse and
respiratory rates were raised later in the evening.
On Friday morning, the surgical registrar who saw Mr A thought
he was looking better. The treatment plan was updated: antibiotics
and antiemetics discontinued, IV fluids decreased, oral fluids
increased and Fortisip[15] if tolerated.
However, later in the day Mr A was reported to be hot and sweaty.
This was reported to a house officer, who requested a chest X-ray
and follow-up bloods. Mr A was reviewed at 2.30pm by a trainee
intern, who thought Mr A was possibly dehydrated and/or had an
infection. The recorded plan was for 500ml saline, a fleet enema[16], and follow-up of
urine test and chest X-ray results.
Mr A's condition continued to deteriorate throughout the
evening. At 8.10pm he was seen by another house officer, who
consulted with a registrar and commenced nasal oxygen, restarted IV
antibiotics and increased IV fluids. Mr A was to have repeat blood
tests and an abdominal CT scan, and hourly observations.
At 11.20pm Mr A was seen by an anaesthetic registrar, Dr O, who
organised for him to be transferred to the High Dependency Unit
(HDU). Dr O then spoke with anaesthetic consultant Dr N, and
recorded in Mr A's progress notes: "In view of medical and social
background this man is not suitable for ventilation or HDU
admission." The DHB subsequently explained that it was "[Mr A's]
significant pre-morbid physical limitations (intellectual
disability has no bearing on this) which were the determining
factors in the decision not to offer invasive ventilatory support".
The DHB explained that this decision was based on the physiological
effects of the intubation and ventilation process coupled with Mr
A's physical condition, meaning that ventilation would likely have
significant long-term outcomes.[17]
Dr O reviewed Mr A again at 11.45pm and discussed his condition
with Ms D and another IHC community services worker. The IHC
Community Services Manager on call, Mr R, arrived in response to Ms
D's concern. The nursing note entered at 1.30am records a
discussion between Mr R and the nurse looking after Mr A at this
time, about the "ceiling" on Mr A's treatment and the need for a
review of his resuscitation status. The nurse noted: "That is a
decision that needs to involve the [IHC] area manager and his
carers so at this stage will hopefully do this morning." Mr R
recalled that staff advised him that intubation had been refused,
as the duty management team considered it would be inappropriate in
view of Mr A's intellectual disability and previous quality of
life.
The DHB subsequently advised that in situations when any
patient's condition is critical and the outcome of resuscitative
events may be ambiguous, it is usual to establish "advance orders".
It is preferable that such discussions occur before, rather than
during, a critical event. The DHB stated that when IHC staff were
asked about resuscitation, this was not in relation to Mr A's
disability, but the likely outcome of resuscitation.
Saturday
Mr A was transferred back to the surgical ward at 2.45am. Soon
after this, he developed respiratory distress and stopped
breathing. Mr R was asked if Mr A was for resuscitation and advised
that in the absence of any documentation, he was. An arrest call
was made and CPR commenced. The arrest team arrived and
resuscitation efforts continued, but Mr A remained unresponsive. At
3.25am resuscitation was stopped. Mr A died at 3.30am.
Mr R reported that hospital staff tried to comfort him after Mr
A's death by commenting that Mr A had been released from "a poor
quality of life". The DHB acknowledged that this was not
appropriate and apologised for this comment.
Cause of death
The coroner was advised of Mr A's death that morning. The
post-mortem concluded that the cause of death was:
"[B]ronchopneumonia of aspiration
type secondary to gallbladder disease which was appropriately
treated surgically. His pre-existing neurological condition is
likely to have predisposed him to aspiration."
Response from Hutt Valley District Health Board
Staffing of ED
The DHB provided details of medical and nursing staffing levels
in ED on the day Mr A was admitted. There were six nurses and a
charge nurse on duty from 7am to 3.30pm, seven nurses and a charge
nurse from 2.45pm to 11.15pm, and one extra nurse from 12pm to
8.30pm. Medical staff consisted of one senior doctor (consultant or
senior medical officer) and one junior doctor (senior house
officer) from 7am to 3pm, and another senior doctor and junior
doctor team 3pm to 11pm. Another junior doctor worked 11am to
9pm.
The DHB advised that at the time of Mr A's presentation, despite
its recruitment efforts within New Zealand and overseas, permanent
medical staffing numbers were around 60-70% below budgeted levels.
The shortage of ED medical staff was discussed at a clinical heads
of departments meeting shortly before Mr A was admitted, and an
arrangement was made for gaps in ED rosters to be filled with
specialist staff and junior medical staff from other departments.
This continued until August 2008, when ED staffing reached its full
complement. The DHB therefore accepts that staffing levels were
inadequate but states that reasonable steps had been taken to
address the issue.
The DHB advised that there is no policy on the maximum length of
stay in ED, but acknowledged that the length of time Mr A waited to
be seen by the ED doctor and then by the surgical registrar was
excessive. However, the DHB considered that the delay in Mr A's
admission to a ward did not delay the start of appropriate
treatment, although it acknowledged and apologised for the delay in
providing pain relief.
On the day Mr A was admitted, 119 patients attended ED
(including patients referred by GPs).[18]
There were 10 patients in ED when Mr A arrived at 9am, including
patients still in ED from the day before (when 104 patients had
attended ED).
Actions taken
The DHB noted that the documentation by RN Mr F was not
adequate. He has been counselled on his lack of documentation in Mr
A's case, and a review of his documentation practice was
undertaken. The DHB reports that there has since been a marked
improvement in RN Mr F's documentation and physical observation
note-keeping.
Although the DHB acknowledged that observations of Mr A's vital
signs could have been taken more frequently while he was in ED, it
advised that he was observed in between times. Moreover, the
failure to take more frequent recordings did not impact on the
state of his health and would not have changed his treatment. The
DHB also considered that while it was unfortunate that the
catheterisation of Mr A required several attempts, male
catheterisation can be difficult, so it is not unusual for more
than one attempt to be needed (although not with the same
catheter). The DHB recognised that the nature of Mr A's illness
affected his ability to respond, but advised that he received full
resuscitative efforts.
The DHB has implemented several changes since Mr A's admission,
primarily in relation to ED staffing. These include:
- An increase in consultant level staffing from 1.5 to 4
full-time equivalent (FTE) fellows of the Australasian College of
Emergency Medicine.
- A full complement of Senior House Officers (SHOs) enabling two
SHOs to be rostered on night duty.
- Improvements to roster patterns.
- Implementation of an ED Staffing Contingency Plan, whereby a
Senior Medical Officer is on call in the event of unavailability of
rostered staff or "excessive demand that outstrips available
resources".
- ED nursing documentation is now audited on an ongoing basis as
part of routine quality improvement.
- An escalation plan has been introduced so that when ED is busy,
supervising nursing staff can be redeployed and extra staff can be
called in to assist.
In addition, the DHB advised that the development of a new ED
due for completion by December 2011, which will be twice the size
of the existing department, should improve patient flow and
observation of patients in less cramped conditions. Similarly, the
development of an Admission and Planning Unit (also due for
completion by December 2011) will better meet the needs of patients
needing more extensive tests and observation prior to admission or
discharge.
Independent advice to Commissioner
Independent advice was obtained from Dr Garry Clearwater in
relation to the care provided to Mr A by the Emergency Department
(Appendix 2) and by Dr Andrew Connolly in relation to surgical care
(Appendix 3).
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability
Services Consumers' Rights are applicable to this complaint:
RIGHT 1
Right to be Treated with
Respect
(1) Every consumer has the right to be treated with
respect.
RIGHT 4
Right to Services of an
Appropriate Standard
(1) Every consumer has the right to have services
provided with reasonable care and skill.
…
(3) Every consumer has the right to have services
provided in a manner consistent with his or her needs.
Opinion: Breach - Hutt Valley District Health Board
Introduction
Mr A did not receive an appropriate standard of care at Hutt
Hospital. My main criticisms are with the care Mr A received while
he was in ED. Substandard care on the part of some clinicians was
combined with unsatisfactory systems and inadequate communication
between ED staff, and with Mr A and his caregivers. While I
acknowledge that it was a busy day in ED and the department was
understaffed, this cannot excuse what amounted to a collective
failure to respond to the needs of Mr A. As my emergency medicine
expert, Dr Garry Clearwater, advised: "He clearly had special needs
and was unable to communicate clearly - such a patient usually
warrants extra attention because the usual clinical clues are
subtle."
It is not possible to determine the extent to which the
shortcomings in Mr A's care at Hutt Hospital contributed to his
death. Mr A's condition was serious and he required major abdominal
surgery. His disability made clinical assessment of his medical
condition more difficult and increased the risks of him developing
postoperative surgical complications. My surgical expert, Dr Andrew
Connolly, found that overall the surgical care provided was of a
high standard. However, Dr Clearwater refers to substandard aspects
of Mr A's care in ED.
In my view, the DHB failed to provide Mr A with an appropriate
standard of care in the ED, and therefore breached Right 4(1) of
the Code for the reasons outlined below. It is also apparent that
the DHB failed to ensure staff treated Mr A with respect and
provided services in a manner that was consistent with his needs.
In this way, the DHB breached Rights 1(1) and 4(3) of the Code.
Care in the Emergency Department
The care Mr A received during the time he spent in ED was
substandard in several respects. Following an investigation into
care provided to a patient by Canterbury DHB,[19] the Commissioner
highlighted the threat posed to patient safety by overcrowding in
ED. His comments in relation to that case apply similarly to Mr A's
situation:
"The heavy workload ED staff faced …
impacted adversely on their standard of assessment, communication
and documentation. A district health board has a duty to provide an
emergency department that has sufficient staff and adequate systems
to withstand fluctuating demands. While the DHB had recognised its
staffing issues and taken steps to address these, these were not
sufficient.
Delays
Mr A was in ED for more than 15 hours. While there is no policy
on maximum ED stays at Hutt Hospital, this was unquestionably too
long for Mr A to wait for surgical review. The DHB apologised for
the unacceptably long delays Mr A experienced, attributing them to
"…the busyness of the clinicians concerned and the requisite
waiting for tests to be completed and reviewed by clinicians before
proceeding to the next step".
On the basis of the information provided, ED does appear to have
been understaffed for the workload on Sunday. However, this is not
an acceptable explanation for suboptimal care. I am especially
concerned about the length of time Mr A waited for his first
medical assessment - more than three hours after triage - and for
his surgical review - more than nine hours after that. Aside from
the implications of this for Mr A's medical condition, it was
particularly unsuitable for a person with needs such as his to
remain in this environment for any longer than absolutely
necessary. While it is not possible to know the extent to which Mr
A's condition deteriorated as a result of the tardy medical review,
the delays were inappropriate and certainly jeopardised the
delivery of care.
As Dr Clearwater states:
"It seems that ED staff did not
consider that [Mr A] was unwell in the first few hours in ED. To
some degree, it is understandable that they were reassured by the
absence of a fever or obvious abdominal tenderness (the latter was
first assessed 3 hours after arrival) but these signs have limited
value in a disabled patient who cannot communicate verbally."
Initial medical assessment
I endorse Dr Clearwater's view that Mr A's initial assessment in
ED was moderately substandard. The extent to which other patients
in ED that day were similarly affected by the understaffing is not
known, but what is known is that Mr A was a particularly vulnerable
patient who did not receive the attention his condition warranted.
In addition to the length of stay and documentation concerns, Dr
Clearwater notes an apparent failure to consider the possibilities
of gallstones and appendicitis. He suggests that an abdominal
ultrasound should have been considered, as an abdominal CT scan "is
not as effective as abdominal ultrasound in diagnosing gallstone
impaction". The DHB subsequently pointed out that ultrasound may
not have shown other possible diagnoses and suggested that it was
safer to look for these before confirming the assumed one. I sought
further comment from Dr Clearwater in relation to this (see
Appendix 2). I accept Dr Clearwater's advice that, while ultrasound
is indeed less effective in diagnosing some other intra-abdominal
conditions, it should have been considered in this case because of
Mr A's history and given that it is a simple procedure not
involving radiation. There is no indication in the notes as to
whether ultrasound was considered.
Nursing care
The nursing care provided to Mr A did not meet standards of
acceptable care in several respects. Mr A's observations should
have been taken more frequently during the morning. As Dr
Clearwater states, this was particularly important for a patient
with undifferentiated pain, who could not communicate well, and who
was waiting for a medical assessment for up to two and a half hours
beyond the time recommended at triage. In addition, there is little
indication that nursing staff responded appropriately to the
clinical indications that Mr A's condition was worsening.
The nursing note at 3pm indicated that Mr A was in no acute
pain. This is contrary to the account given by IHC staff and their
requests to nursing staff throughout the day for Mr A to be given
pain relief. IHC staff familiar with Mr A were better able to
interpret his non-verbal cues and were with him throughout his time
in ED. It is likely that the written information from Ms D was
provided while Mr A was still in ED, although it may have been late
in the day. Irrespective of this, IHC staff were available at all
times and were a valuable source of information.
I agree with Dr Clearwater that "ED staff were misled by [Mr
A's] limited ability to convey pain (with grimaces and subtle
cues)… [and] … gave insufficient weight to the concerns of his
caregivers who repeatedly conveyed that he was in distress and
needed pain relief".
The DHB accepted that its staff should have explained to IHC
staff that oral pain relief could not be given until Mr A had been
seen by the surgical team. However, this does not explain why
other, non-oral pain medication was not given earlier in the day.
While pain relief was ultimately the responsibility of the doctor
looking after Mr A at the time, I find no evidence to indicate that
nursing staff communicated the need for this to the doctors. It was
more than 10½ hours after Mr A's arrival in ED before he was given
pain relief or fluids. This was clearly not acceptable.
Moreover, there is no indication that nursing staff informed
medical staff that Mr A had vomited. Medication to alleviate nausea
and vomiting could have made Mr A more comfortable, as well as
possibly preventing the aspiration of vomitus.
There were also issues with the management and recording of Mr
A's catheterisation. Staff who inserted the catheter and
nasogastric tube had documented these procedures, although there is
still no record of the size of the catheter, and the entry was not
signed. However, the documentation from ED was copied into Mr A's
inpatient notes before this note was made, so it was an incomplete
record that accompanied Mr A to the ward and that staff caring for
him there relied on. This raises yet another concern about ED
systems, with the potential to result in serious harm if not
addressed satisfactorily.
Aside from this, the nurse involved acknowledged that several
attempts were made to insert the catheter. As Dr Clearwater states,
urinary catheterisation is potentially a painful procedure with a
risk of inducing permanent injury. He considers it should be
uncommon to have to make more than one attempt and states that
"[i]f a catheter cannot be inserted readily (maximum two attempts),
a more experienced staff member should be consulted; it is risky to
repeatedly attempt to re-catheterise a patient".
The DHB advised that all ED nurses performing male
catheterisations must be trained to do this. What happened with Mr
A - multiple attempts and repeated use of the same catheter -
certainly indicates that the staff members involved need further
training.
Documentation
The documentation of Mr A's medical care while he was in ED was
not of an acceptable standard. Of note is the lack of clarity in Dr
G's records, including the fact that he can only say it is "more
likely than not" that he was the author of this record. The use of
the electronic discharge summary as the sole record of medical
input was clearly problematic. It was particularly unhelpful for a
patient whose stay in ED was over 15 hours and whose care was
provided by more than one clinician. As Dr Clearwater states, it is
"… substandard to leave a 'work in progress' electronic discharge
summary as the sole clinical note in a paper-based system".
In a recent report of another investigation into ED care at Hutt
Hospital,[20] the Commissioner referred to
the pros and cons of writing notes directly into an electronic
discharge summary. Following that investigation, the DHB revised
the ED guidelines on the use of electronic discharge summaries in
conjunction with handwritten notes. These guidelines were not in
place at the time of Mr A's attendance, but his experience clearly
reinforces the need for a clinical record that details the full
clinical situation and an explanation for the decisions and action
taken. HDC was also advised at that time that the DHB was
anticipating the incorporation of a free text function in the
electronic record in June 2009, which will allow for more accurate
contemporaneous recording within the electronic record, for the
course of an ED stay.
The absence of nursing progress notes for six hours following
triage is also not acceptable. There are blank spaces in the
nursing records where times should have been recorded, and unsigned
and untimed entries in the IV fluid record make it unclear as to
whether two doses of IV saline fluids were actually
administered.
Conclusion
While individual members of staff must consider their own
practice in light of this case, in my opinion the ED clinical team
as a whole let Mr A down. I am pleased to hear that significant
improvements have been made to medical staffing levels in ED at
Hutt Hospital, including specialist emergency medicine staff.
However, it is clear that the staffing of ED on Sunday was not
adequate. As a result, Mr A waited longer to be seen and treated by
medical staff than was appropriate. The nurses responsible for Mr
A's care in ED did not meet acceptable standards of care, by
failing to take regular observations and failing to respond to
requests for pain relief.
Documentation of clinical observations and decisions is
fundamental to patient care. Yet there were a number of gaps and
ambiguities in Mr A's documentation, particularly the failure by
nursing staff to fully document Mr A's condition and care
adequately.
In my view, these deficiencies were primarily a result of
overcrowding in ED. Staff were rushed, and decisions, assessments
and medical interventions were rushed or truncated as a result.[21] In these
circumstances, Hutt Valley District Health Board breached Right
4(1) of the Code.
Surgical care
I endorse the view of my surgical expert, Dr Andrew Connolly,
that Mr A was provided with satisfactory surgical care aside from
the delay in the initial surgical assessment.
Initial assessment
Although Mr A was referred to the surgical team for assessment
after Dr G saw him at 12.15pm, the admitting surgical registrar, Dr
H, did not see him until 9.30pm that night. Given Mr A's condition,
this was not appropriate. As Dr Clearwater noted:
"It is inadvisable for specialist
services to unduly delay seeing patients that have been referred
for assessment. It is unfair and unsafe for patients to wait a long
time, their condition can deteriorate and it blocks beds in
ED."
However, I accept Dr H's explanation that the information passed
on from ED staff did not indicate Mr A should be reviewed urgently
so, as he was in surgery all afternoon, he did not prioritise
seeing Mr A earlier. I agree with Dr Clearwater that ED staff did
not initially appreciate how poor Mr A's condition was and
therefore "insufficient concern [was] conveyed initially to the
surgical registrar about his condition". Once Dr H assessed Mr A,
he took appropriate action by arranging a CT scan.
Preoperative assessment
I accept Dr Connolly's advice that the decision-making process
regarding preoperative investigations and the timing of Mr A's
surgery was appropriate. Dr Connolly advised that a period of IV
fluid resuscitation is usually very valuable for patients where
there is no clinical indication for immediate surgery.
Standard of surgery, postoperative care and documentation
According to Dr Connolly, Mr A's surgery was appropriate,
beginning with an exploratory laparotomy and proceeding to the
removal of his gall bladder and appendix. The decision to remove Mr
A's appendix was reasonable on the basis of diagnostic uncertainty,
and indeed the post-mortem confirmed that he had acute
appendicitis. The operation record itself is detailed and thorough.
However, a clearer explanation of this could have been provided to
Mr A and his caregivers. I appreciate that staff may have been
attempting to communicate the outcome of surgery in a manner that
Mr A could understand. However, the explanation provided (that they
had removed his appendix "just in case" he ever got appendicitis)
was not accurate and raised questions about the appropriateness of
the treatment.
Dr Connolly advised that Mr A's care was of a high standard and
that he was treated aggressively in the postoperative period. He
noted that the emphasis placed on oxygen saturation levels
post-surgery indicated an awareness of the potential for a person
with an intellectual disability to have an increased risk of
respiratory compromise following abdominal surgery.
It is concerning that Mr A's progress notes refer to his
"medical and social background" as the basis for the decision not
to admit him to HDU or commence ventilation, if his physical
limitations were the determining factor for this decision. However,
I accept Dr Connolly's advice that attempts to resuscitate Mr A
were correctly carried out and the surgical team's documentation
was acceptable.
Informed consent for surgery
A key issue in the complaint from Mr B and IHC was the extent to
which Mr A's surgery was delayed by hospital staff adopting an
overly cautious approach to establishing whether they needed to
obtain informed consent to proceed with treatment.
Right 7(4) of the Code of Health and Disability Services
Consumers' Rights outlines the process required where a consumer is
not competent to make an informed choice and give informed consent,
and no person entitled to consent on behalf of the consumer is
available. It states that the provider may provide services where
(a) it is in the best interests of the consumer; (b) reasonable
steps have been taken to ascertain the consumer's views; and (c)
provision of services is either consistent with the consumer's
views or, if the consumer's views have not been ascertained, the
provider "takes into account the view of other suitable persons who
are interested in the welfare of the consumer and available to
advise the provider".
The IHC staff who were with Mr A for much of his time at Hutt
Hospital and always contactable were certainly "suitable
persons" interested in the welfare of the consumer and available to
advise the provider. It was therefore both necessary and desirable
for IHC staff to be consulted in relation to Mr A's treatment, as
well their assistance sought in ascertaining Mr A's views. There
are a number of instances documented in Mr A's notes of discussions
with IHC staff about his condition and treatment in the surgical
ward, including prior to surgery and when he was transferred back
to the ward in the early hours of the day he died.
Having said that, I can find no evidence to indicate that Mr A's
surgery was delayed by the issue of consent. Once Dr C confirmed
that Mr A required surgery, she sought the opinions of two senior
colleagues unrelated to the direct care of the patient. The
operation took place soon after the decision was made that this was
in Mr A's best interests. Dr C's actions were in accordance with
the DHB's Informed Consent policy, and the process was documented
clearly in the clinical notes.
However, the DHB's Informed Consent policy is not entirely clear
that, where a patient's views cannot be ascertained, staff should
take into account the views of those people who are available and
interested in the patient's welfare. I also note that the DHB has a
form for use with patients unable to give consent, but that the use
of this has not been formalised. I suggest that the DHB revise the
Policy and implement the use of the associated form, to ensure
staff are able to clearly document the process prior to providing
services to a patient not competent to consent.
Consumer-centred care
What is striking about this case is the failure of staff to
listen to Mr A's voice (expressed with the assistance of his
caregivers), and a systemic lack of responsiveness to Mr A's
needs.
It is a core ethical principle in caring for patients that every
patient should be treated with respect. Right 1(1) recognises this
principle as a legal right under the Code, confirming "every
consumer has the right to be treated with respect". I agree with
the Commissioner's statement in Case 05HDC11908:
"Patients who have been admitted to
hospital because they are acutely unwell are especially in need of
care, comfort and compassion. As well as suffering from their
present illness, they are likely to be frightened by the unfamiliar
hospital environment and fearful for their future."[22]
Care, comfort and compassion are particularly important for
someone like Mr A, who was not capable of clearly expressing his
needs, was unable to express the usual cues of pain and distress,
and was known to dislike being in hospital. Furthermore, as Dr
Clearwater noted, a patient such as Mr A "warrants extra attention
and observation because the usual clinical cues are subtle". In my
view, hospital staff did not make the most of the assistance
available from IHC staff to ensure Mr A's care and treatment were
provided in a manner that ensured he was treated with respect and
that his distress and discomfort were minimised. IHC staff
endeavoured to assist the hospital staff in their care of Mr A by
interpreting his limited repertoire of communication skills,
monitoring his temperature and conveying his need for pain
relief.
I have previously noted several instances of less than adequate
communication in relation to Mr A's care in ED and under the
surgical team. This includes the failure of staff to clearly
explain the reasons for some treatments (eg, withholding oral pain
relief in ED and the reason for removing Mr A's appendix) to Mr A
himself, or with his caregivers (who could have explained it to Mr
A). Furthermore, concerns expressed by caregivers to ED staff were
effectively ignored, resulting in Mr A:
- being left in ED with nothing to eat or drink until IV fluids
were started 10 hours after arrival, by which time he was
significantly dehydrated;
- not being given anything for nausea or vomiting - including his
routine medication to prevent regurgitation, increasing the chances
of regurgitation (and aspiration of gastric contents);
- not being given any pain relief, despite repeated expressions
of concern by his caregivers until nearly 11 hours after his
arrival in ED.
I am also concerned by the comment by a staff member shortly
after Mr A's death that he had been "released" from a "poor"
quality of life. There was also reference in Mr A's clinical record
to his "social background" as the basis for decisions about his
care. These are wholly inappropriate comments, and demonstrate a
lack of respect for Mr A and a lack of understanding of his quality
of life. From all accounts Mr A had a degree of independence,
hobbies and interests, and a home with friends. He found much to
enjoy in life and was, for the most part, living an 'ordinary
life', no better or worse than the rest of us. I am also left with
some disquiet about the reasons for not admitting Mr A to HDU for
more aggressive treatment. To not admit Mr A to HDU was a
significant decision, which should at least have been fully
discussed with IHC staff (as suitable persons who were interested
in his welfare) before the decision on which treatment option to
pursue was made.
The DHB, as an organisation, is responsible for the attitude
that its staff displays to patients.
While it is not possible to verify exactly what was said to, or
about, Mr A during his time at Hutt Hospital, I am left with a
clear impression that he was not accorded the basic dignity and
respect that is the right of every patient. Staff clearly did not
respond appropriately to concerns raised by Mr A's caregivers that
he was in pain, was vomiting and needed his regular medication.
Accordingly, I conclude that in its treatment of Mr A, Hutt
Valley District Health Board breached Rights 1(1) and 4(3) of the
Code.
Hutt Valley District Health Board's Summary Report on the care
of a patient with a severe disability
In May 2009, the DHB released a Summary
Report on the care of another patient with a severe disability,
identified as Ms A. Ms A was admitted to Hutt Hospital in May 2008,
and died 18 days later. The DHB considered that Ms A's disability
needs may not have been considered as part of her overall care
plan, and commissioned an independent external review. The Summary
Report identifies a number of significant concerns with the care
provided to Ms A, and concludes with 24 recommendations.
Several of the concerns identified and recommendations made are
pertinent to Mr A's experience. I note the following in
particular:
- Recommendation 3 - "That all staff attend disability
responsiveness training to improve their competence to care for
people with disabilities as stated in the Hutt Valley District
Health Board's New Zealand Disability Strategy Implementation Plan
2006-2011."
- Recommendation 5 - "Working in partnership with disability
providers and people with disabilities to develop processes that
ensure staff have the information they need and people with
disabilities are able to have their disability support needs
met."
- Recommendation 10 - "Develop a process whereby patients with
high and complex needs have an assigned senior nurse to provide an
ongoing overview of the patient, nursing care planning and
priorities within the multidisciplinary team."
- Recommendation 14 - "Consider developing a process whereby
patients with high and complex needs are allocated a named
individual to act effectively as an advocate/case manager during
any admission, specifically to take a helicopter view of the
patient's care and ensure issues not commonly encountered by acute
ward staff in caring for patients can be addressed promptly and
effectively."
I note also Recommendation 2, that a memorandum of understanding
or protocol is developed between the DHB and the particular
accommodation Trust involved in Ms A's situation, to specify each
organisation's obligations when a resident is in hospital. It would
be appropriate for this to be extended to other disability service
providers.
The DHB has advised the Commissioner that while some changes
have been made as a result of this review, some recommendations
will take time to implement. The review is an important step and I
commend the DHB for recognising the learning that can come from an
honest and open appraisal. Furthermore, the decision to share the
lessons learned with other DHBs ensures that the wishes of Ms A's
family and supporters that Ms A's experiences should be a catalyst
for change are realised more fully.
Response to provisional opinion
The DHB has accepted all of the deficiencies of care outlined in
this opinion. In particular, it recognises and accepts that the
reduced numbers of staff in ED on the day he was admitted
contributed to the poor care Mr A received. The DHB agrees that Mr
A's needs as a disabled person were not appropriately addressed and
has reiterated its commitment to implementing the changes
recommended following the recent external review.
The DHB offers its sincere apologies to Mr A's caregivers and
friends for the poor standard of care and communication provided to
Mr A.
Recommendations
I recommend that Hutt Valley District Health Board provide to
HDC by 30 November
2009:
Follow-up actions
- A copy of this report will be sent to the Chief Coroner.
-
A copy of this report with details identifying the parties
removed, except the experts who advised on this case, IHC, Hutt
Valley District Health Board and Hutt Hospital, will be sent to the
Minister of Health, the Director-General of Health, the Medical
Council of New Zealand, the Australasian College of Emergency
Medicine, the Quality Improvement Committee, the Health Information
Strategy Advisory Committee, all district health boards, the New
Zealand Nurses Organisation, the New Zealand Medical Association,
and the Association of Salaried Medical Specialists, and will be
placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational
purposes.
Appendix 1 - ED Observations (PDF)
[refer to pdf document to view
image]
Appendix 2 - Independent advice from Dr Garry Clearwater
Thank you for asking me to review this case.
I have read and agreed to follow the Guidelines for Independent
Advisors provided by the Office of the Health & Disability
Commissioner.
I am an Emergency Medicine specialist, qualified MBChB in 1982
and a Fellow of the Australasian College for Emergency Medicine
(FACEM) since 1999. I currently work as a full-time staff
specialist in two Emergency Departments (EDs) at Waitemata District
Health Board and I was Clinical Director of the Emergency Medicine
service between 2000 and early 2006. I have previously worked as a
GP in a semi-rural practice and as a Medical Officer of Special
Scale at Middlemore Hospital ED. Our service employs specialists,
Senior Medical Officers and registrars in training as well as
locums. We employed Senior House Officers up until 2005 and have
Senior House Officers on staff since November 2008.
I have been asked to provide independent expert advice regarding
the standard of care provided to [Mr A] in the Emergency Department
of Hutt Hospital during his admission on Sunday [in early] 2008,
prior to his admission to the care of the surgical service of that
hospital later that evening.
[Dr Clearwater noted here the documents he reviewed and a
summary of events.]
Questions raised by the Commissioner
1.The general care provided by Hutt Hospital
ED.
This was sub-standard in a number of ways.
Key concerns include:
Significant delay to be seen by a doctor: the
first medical assessment was at 1215h, more than 3 hours after
arrival in ED - despite a Triage category of 3 (should be seen by a
doctor within 30 minutes).
[Mr A] did not receive adequate attention for his
condition. He clearly had special needs and was unable to
communicate clearly - such a patient usually warrants extra
attention and observation because the usual clinical cues are
subtle. His caregivers were familiar with his normal state and were
appropriately concerned enough to seek hospital attention. Their
concerns expressed to ED staff were not given appropriate weight,
and I suspect that his underlying illness was underestimated
because he could not express himself clearly.
- He was apparently left with nothing to eat or drink until IV
fluids were started 10 hours after arrival - by which time he was
significantly dehydrated. It was a very simple and standard process
to chart intravenous fluids in ED for patients who cannot eat or
drink.
- His routine medication to prevent regurgitation (Domperidone)
was withheld, despite enquiries from the caregivers, increasing the
chances of regurgitation (indeed, the caregiver documents him
swallowing his vomitus). Aspiration of gastric contents is likely
to have been a contributor to his death.
- He was not given anything for nausea or vomiting in ED although
this could easily have been given as a dose of metoclopramide, used
routinely in EDs for this problem.
- Pain relief was delayed, until 1945h (nearly 11 hours after
arrival) - not even a simple analgesic such as paracetamol -
despite repeated expressions of concern by his caregivers.
The description of 3 attempts to insert a urinary
catheter (as described by his IHC caregiver -
there is nothing in the clinical notes) suggests that a
staff member lacking full competency attempted the
procedure. The unidentified staff member was observed to
make multiple unsuccessful attempts to insert the catheter; it was
eventually deemed to be curled under the foreskin - from which I
infer that the foreskin was not retracted when it should have been
(a basic preparation); there was likely to be inadequate
preparation and cleansing before insertion. Furthermore, the next
staff member who successfully inserted the catheter (after
retracting the foreskin) reportedly re-used a catheter that had
been curled under the foreskin and reportedly had inadequate
anaesthetic for the procedure.
2. Was [Mr A] adequately assessed in ED?
I support the concerns expressed by the IHC (particularly on
pages 00008-9) that [Mr A] may not have received the same standard
of care as a more able-bodied articulate patient would have
received.
Overall, his assessment seems to have been moderately
substandard: it was delayed, suboptimally documented, did
not take into account the limitations attributable to his
disabilities and was in some respects neglectful.
It seems that ED staff did not consider that [Mr A] was unwell
in the first few hours in ED. To some degree, it is understandable
that they were reassured by the absence of a fever or obvious
abdominal tenderness (the latter was first assessed 3 hours after
arrival) but these signs have limited value in a disabled patient
who cannot communicate verbally.
My impression is that ED staff were misled by [Mr A's] limited
ability to convey pain (with grimaces and subtle cues). ED staff
gave insufficient weight to the concerns of his caregivers who
repeatedly conveyed that he was in distress and needed pain
relief.
The possibilities of gallstones and appendicitis were
not considered in ED. [Mr A] was known to have gallstones
(and was a previous candidate for cholecystectomy). He presented
with abdominal distension and pain but no consideration seems to
have been made for possible biliary colic (gallstone pain:
cholelithiasis) or infection (cholecystitis) even when he developed
fever and was noted to have an elevated white cell count.
Normally, a patient presenting with abdominal pain and known
gallstones would have this possibility high on the differential
diagnosis. It is unclear whether an abdominal ultrasound (a
non-invasive diagnostic test) was considered at any time or (if it
was considered) why it was not performed. Abdominal CT scan is not
as effective as abdominal ultrasound in diagnosing gallstone
impaction.
Symptoms and signs of appendicitis can be difficult to elicit in
patients who cannot communicate clearly but this was also a
possibility in a patient with abdominal discomfort, anorexia or
vomiting, especially as he developed increasing signs of
infection.
An impacted gallstone and appendicitis were both found at
surgery the next day.
According to IHC staff, it was the caregivers who first recorded
a fever in ED at 2010h and notified the nurses but this was not
checked or recorded by nursing staff until 2202h.
It is difficult to know whether all patients in the ED were
equally affected by heavy workload but this patient was especially
vulnerable and warranted a higher level of basic care than was
provided. His condition clearly deteriorated in ED such that he was
eventually judged to be dehydrated, in pain, feverish, had vomited
and may well have aspirated during that time.
3. ED workload and staffing levels.
Insufficient information was provided to judge this
accurately.
Two staff members did not mention workload concerns in their
responses (RN [Mr F] #00042, [Dr G] ##00043).
The Nurse Manager described the workload (#00056): 119 patients
attended the ED on [the day Mr A was admitted]. However,
supplementary data is needed to better assess workload. Some of
these statistics constitute Key Performance Indicators for many
EDs.
How many of these attendances were GP referrals to services
other than Emergency Medicine? GP referrals typically constitute
between 15-35% of cases presenting to ED [and] are primarily seen
by other doctors from inpatient services.
Patient numbers presenting within time intervals (e.g. each
hour). Workload may be reasonable for part of the day and then
become heavy as patients present in clusters.
Distribution of patients amongst the triage categories. A high
number of sick patients (triage categories1-3) take up more medical
time on average than the same number of low-acuity patients (triage
4-5).
Average lengths of stay in the ED; a measure of delays and
workload.
The percentage of patients seen within their target times in
each triage category: a measure of how far the medical staff were
falling behind the workload.
Admission rates: a threshold measure of how many patients were
sick enough to need admission to a ward.
The number or percentage of patients who left without being
seen.
Medical staffing levels stated by the Nurse Manager:
One Senior Medical Officer (SMO) and one Senior House Officer
(SHO) between 0700-1500h (I suspect this was meant to be between
0700 and 1600h, judging by [Dr G's] comments
#00043).
One SHO between 1100 and 2100h.
One SMO and one SHO between 1500-2300h (I suspect the start time
was actually 1600h, from Dr L's comments #00044).
One SHO on the night shift (2300-0700h).
I presume that these staff numbers do not include inpatient team
doctors who were assessing and admitting referred patients in
ED.
Based on this limited data, one interpretation is that 119
patients were assessed by 6 doctors (providing 44 doctor-hours)
over 24 hours: an average of 2.7 patients per hour per doctor, for
all acuities. The standard processing rate for ED patients is 1-2
patients per doctor per hour (closer to 1 patient per hour for a
busy metropolitan ED with high-acuity patients).
However, if the total of 119 patients included GP referrals,
there may have been 77-100 patients to be assessed by Emergency
Medicine doctors: an average of about 2 patients per doctor per
hour.
The comments by the ED consultant on the afternoon shift were
pertinent (#00044): "my other recollection of that day … was the
exceptionally large workload - I had already attended the
department for an extra 6 hours earlier in the day (0000-0300 and
1115-1415) due to the overwhelming workload. Both medical and
nursing staff were struggling to maintain timeframes and optimal
patient care."
Thus, with the limited information provided, ED was
apparently understaffed for the workload and suboptimal care was to
be expected.
Note, in relation to the next question, I cannot comment
on the workload for the surgical service.
4. Length of stay in ED before transfer to the surgical
ward.
The duration in ED was excessive, at more than 15 hours. There
were a number of factors: delayed ED medical assessment, waiting
for results of tests, initial underestimation of the patient's
condition and perhaps insufficient concern conveyed initially to
the surgical registrar about his condition (leading to lower
priority and consequent delays by the surgical service).
The net effect was suboptimal patient care:
The ED environment is often chaotic and stressful for some
patients who would be better served in the settled environment of a
ward.
Compared to ward beds, ED stretchers are typically unsuitable
for prolonged bed rest.
Overload in ED is primarily attributable to delayed access to
inpatient beds. Patients who wait in ED take up resources
(especially nursing time) that primarily should be used to manage
acute patients. There is plenty of evidence that patient mortality
and morbidity deteriorates when access to inpatient beds from ED is
delayed.
5. Time taken to be seen by the surgical team to assess
[Mr A].
This is difficult to determine because documentation is unclear
as to when the surgical team were specifically asked to
assess/admit [Mr A].
His first ED medical assessment was at 1215h followed by
abdominal X-rays at 1300h. The surgical registrar was consulted (by
phone) with the results of the X-rays but there is no indication of
when this happened - presumably some time after the abdominal
X-rays, early in the afternoon. It seems that there was low concern
about the patient's condition ("habitual constipation"); a plan was
discussed (to await blood test results) that did not necessarily
require surgical assessment.
An ED specialist assessed [Mr A] at 1730h and took a second set
of blood tests. The notes are over-written in such a way as to be
unclear when these results were reviewed and when the surgical
registrar was formally asked to assess the patient for admission.
However, the ED consultant states in retrospect (#00044) that she
was "certain" that an attempt was made to contact the surgical
registrar at the time that she assessed [Mr A]: presumably
somewhere between 1800 and 1830h (after assessing [Mr A]).
According to the ED Nurse Manager (#00057), the surgical
registrar did not come to see the patient until "completion of
surgery at approximately 9:30 PM" but then realised that, "[Mr A]
was sicker than had been inferred from the handover information
provided him. [Dr H] advised that if he had realised this he would
have come to see [Mr A] earlier, between surgical cases." It is
unclear whether [Dr H] was referring to the first discussion (by
[Dr G]) or the later referral by the ED consultant.
This suggests that the surgical registrar could have reviewed
[Mr A] earlier if he wanted.
It is inadvisable for specialist services to unduly delay seeing
patients that have been referred for assessment. It is unfair and
unsafe for patients to wait a long time, their condition can
deteriorate and it blocks beds in the ED. Sometimes the severity of
the patient's condition is underestimated at the time of referral
by the ED doctor or only becomes apparent with time.
The ACEM Policy on the Definition of an Admission (2006)
includes the following points:
2.4 The Australasian College for Emergency Medicine believes the
emergency department is not an appropriate environment for the
ongoing management of patients who require inpatient medical
care.
2.5 Where a patient is assessed in the emergency department as
requiring admission as an inpatient then a bed should be made
available at the delegated receiving unit as soon as possible.
2.6 The Australasian College for Emergency Medicine believes
retention of admitted patients in the emergency department is a
failure of access to care and is detrimental to emergency
department function.
3.2 The time admission is requested should be recorded to the
nearest minute.
3.3 The time the admitted patient leaves the emergency
department should be recorded to the nearest minute.
In summary, most of the delays in ED were attributable to serial
delays by ED staff (delays to be seen and delays getting adequate
lab samples) but there was a further delay of 3-4 hours for the
surgical registrar to come to see [Mr A] after he was referred.
Management at Hutt Valley DHB have acknowledged that the
delay was unacceptable (#00058): "we apologise… for the
excessive wait [Mr A]… experienced in ED while waiting for the
surgical registrar… we do accept that specialist staff should have
seen him earlier and that he would have been more comfortable in a
ward bed."
6. Documentation by Hutt Hospital's ED staff.
The nursing notes (#00089, #00095-6)
were substandard, to a moderate degree.
There were no nursing recordings of vital signs between 0859 and
1200h: a gap of 3 hours, during which time no doctor had seen the
patient.
There were no nursing progress notes between 0859h and 1500h: a
gap of 6 hours.
The nursing record has blank spaces in the sections where times
should be recorded (time of investigations, finish time for IV
fluids).
In the IV fluid section, an unidentified staff member has
recorded "IV saline" 2 litres to be given IV "stat" but this
section is unsigned and it is therefore unclear whether or not the
fluid was administered.
There is no nursing record of the information conveyed from [Mr
A's] caregivers (as recorded on #00012), including their concerns
that he was in pain, was vomiting and needed his regular
medication.
The recordings between 1200h and 2200h show a steady rise in
pulse rate: potentially an indicator of deteriorating pain or
hydration or infection; there is no evidence that this evoked any
response from nursing staff.
The documentation by [Dr G] (#00090-91) was suboptimal to a
moderate degree.
In his response dated 21 July 2008 (#00043), [Dr G] provides an
indictment of his own documentation when he states that he cannot
be sure from the notes that he actually saw the patient. The
electronic record had another doctor's name on it and he is not
convinced that he was the author apart from his impression they
were "written in a format consistent with my own." At best, "more
likely than not," he admits that he was probably the author.
This is a basic failure of documentation. [Dr G] should have
written or printed out his notes and signed them at the time of his
assessment as a basic standard of medical care, before he handed
over his patient and left the ED.
Instead, they appear to have been written into an electronic
discharge summary without being printed out and signed. The EDS
system has subsequently automatically over-written his name.
The time frames within his electronic clinical note are unclear
and it appears that text segments were added through the shift: at
one point it states that "CRP still pending" but in another part
(in what was presumably an untimed addition) records the CRP
value.
[Dr G's] notes give no indication when the surgical registrar
was contacted (see the reference to ACEM policy 3.2, mentioned
above).
The interim plan is equivocal: it states that the surgical
registrar "will review" but then equivocates: "or could consider
(discharge) … if inflammatory markers are (normal)".
The record records mild elevation of CRP but omits the white
blood count. [Dr G] later stated that the latter sample had clotted
and needed to be repeated. This was not documented anywhere in the
notes and added to the delays in [Mr A's] care.
Regarding hand over, [Dr G] offers in retrospect that "I
probably handed the patient's care over to [Dr L] to chase up the
laboratory results…"
The issue of writing notes directly into an EDS (without
separate clinical notes) was raised in respect to another ED case
from Hutt Valley DHB that occurred in 2006 (07/10767).
While this system is suitable for straightforward clinical problems
where the same doctor discharges the patient, it is unsuitable for
patients with complex problems where the case is being handed over
to another doctor.
The notes by [Dr L] (#00092) are of a good
standard and make it clear that a surgical opinion was
requested although it does not indicate when this request was
made.
There were significant delays in ED pending the results
of lab tests but documentation of this was mildly below
standard. There is virtually no documentation of what
results were ordered and when. In his retrospective report
(#00043), [Dr G] states that some of the samples had clotted,
requiring repeat tests: this should have been documented in the
notes.
Regarding the urinary catheter, documentation was mildly
below standard. There was no clinical documentation of the
catheter insertion time, catheter size or results of
catheterisation.
7. The standard of communication by Hutt Hospital ED
staff with [Mr A] and his caregivers.
It seems that his caregivers made a great effort to assist the
ED staff in their care of [Mr A]. They were always present to
support their client and to interpret his limited repertoire of
communication skills. They actively assisted with his care,
including apparently taking his temperature and conveying his need
for pain relief.
An undated, unsigned clinical sheet (#00097-8), presumably
written by his caregivers, has more than a page of detail "from [Mr
A's] carers for nursing staff" regarding how he conveyed feelings
of pain, how stressed he was likely to be in hospital, the
anticipation that he would try to remove his intravenous line and
catheters (and how to deal with this), how he could be offered
fluids, how to tell when he was happy and how to assist his
mobility. A contact number was given for further advice if this was
needed.
The caregiver report (#00012) indicates that nurses were
informed at arrival in ED that [Mr A] was indicating pain but this
was not clearly documented in the nursing notes and the issue
appears to have been ignored until a nurse asked at 1130h what type
of pain relief he could have. The caregivers suggested paracetamol
but no analgesia was given then.
Pain relief was reportedly requested by the caregivers again at
1530h - this was not documented in the nursing notes or actioned.
Further requests for pain relief were made at 1800h (again, not
documented) but analgesia was not started until 1930h.
They describe two occasions where nurses promised to return with
answers to questions (at 1445h, 1930h) but did not return.
The communication from the ED staff was moderately below
standard despite a high level of involvement and support by [Mr
A's] caregivers.
8. Changes that Hutt Valley DHB staff have made since
these events.
There seem to have been significant improvements in medical
staffing levels on weekends (#00056) - when EM workload is
typically busiest. An extra SMO works between 0900-1700h and an
extra SHO on the night shift: effectively providing an extra 16
doctor-hours per 24 hours.
In the absence of data about typical presentation numbers on
weekends, it is difficult to comment whether this is adequate for
workload but it is certainly an improvement.
Comments in the reply from Hutt Valley DHB indicate that
some deficiencies were under-estimated:
A. Urinary catheterisation is a potentially painful
procedure with a risk of inducing permanent injury. I am concerned
about the assertions made in section c on Page 00033 by the Service
Manager of Acute Services regarding male catheterisation that, "it
is not unusual for the need for several attempts." It should be
uncommon to have to make more than one attempt - and I invite this
issue to be reviewed by a urologist. If a catheter cannot be
inserted in the first attempt, a more experienced staff member
should advise and assist; it is risky to repeatedly attempt to
re-catheterise a patient.
At the very least, the staff member who made the initial attempt
needs to be identified and educated. There may be a systems problem
(of education, guidelines and credentialing) that needs wider
attention.
B. Recording vital signs. Later, in the same page,
there is the statement that "3 hourly observations of vital signs"
were adequate in ED and "the failure to take more frequent
recordings did not impact on [Mr A] (sic) state of health and would
not have changed any of the subsequent actions."
This is not an acceptable standard in ED, particularly for a
patient with undifferentiated pain, who cannot communicate well and
was awaiting medical assessment by a doctor, up to two and a half
hours beyond the time recommended at triage.
9. Recommendations
ED staff may need education about how to assess and assist
disabled patients, including education that:
Some disabled patients do not convey standard cues to distress
or pain;
Caregivers who know the patient well are a very useful source of
advice for interpreting the needs of individual patients.
Documentation standards could be improved to
provide an accurate record of assessment, initial differential
diagnosis and management plan - ideally updated in a sequential
manner with key information as it comes to hand.
A guideline is recommended about when it is appropriate to
write clinical notes into the electronic discharge summary
for this ED that uses a mixture of hand-written clinical notes and
electronic discharge summaries. I suggest that each patient who is
handed over to another doctor (or is referred to another service)
should have a printed record in the notes, timed and signed by the
doctor who assessed the patient. It is substandard to leave a "work
in progress" electronic discharge summary as the sole clinical note
in a paper-based system.
Shift scheduling may be unrealistic. The shift
times provided by the ED Nurse Manager (#00056) did not match the
information provided by doctors (as discussed in Question 3.)
Of concern, if they are correct, the intervals do not account or
allow for systematic review and handover of patients at each shift
time. One shift is apparently scheduled to finish at 1500h, the
next starts at 1500h: it is unrealistic to think that staff on one
busy shift can suddenly finish all their tasks and leave at the
exact time as a new shift starts.
There should be a minimum of 30-60 minutes of shift overlap to
allow for systematic handover. I presume that time is actually
being taken for this but it would be disappointing if roster
scheduling does not recognise this basic requirement.
There is no evidence as to whether a guideline exists
regarding urinary catheterisation. There should be a service
guideline (with input from the Urology service) that includes:
Urinary catheterisation should be performed by a credentialed
staff member.
If a catheter cannot be inserted readily (maximum 2 attempts), a
more experienced staff member should be consulted; it is risky to
repeatedly attempt to re-catheterise a patient.
The time, size and type of catheter should be documented as well
as the amount of fluid drained.
10. Additional comments
A. The ED consultant seems to have worked excessive hours that
weekend (as mentioned in Question 3). Hopefully this was
exceptional; error rates increase when doctors work excessive hours
at a busy pace.
B. The staff responses provided by [Mr F] (#00042) and [Dr G]
(#00043) indicate that they may not have been adequately informed
that they were involved in the investigation of a significant
incident. I wonder whether they were advised to contact their
professional indemnity advisor before tendering their
responses.
It should be part of departmental policy to advise key staff
members to consult with their indemnity and/or professional
advisors when giving reports about serious incidents.
C. There is no indication in the records provided to me of [Dr
G's] level of experience or expertise: he is simply described as
"an ED Medical Officer."
It would be useful to know more about his level of ED experience
and training as well as whether he was a supervisor or was under
supervision of a more senior doctor.
Additional comment from Dr Clearwater in relation to the
need to consider an abdominal ultrasound.
I am not an expert in surgical problems or radiological
investigations. My comments were based on the fact that [Mr A] was
known to have gallstones and had been considered for surgery for
these prior to his acute visit. Our radiology service has pointed
out in the past that an ultrasound is most effective for diagnosing
impacted gallstones and cholecystitis (inflammation around the
gallbladder). In my experience, if a patient has unexplained
abdominal pain and a known history of gallstones, an ultrasound
will be suggested because it is a simple procedure, not involving
radiation.
However, ultrasound is indeed less effective in diagnosing some
other intra-abdominal conditions and requires an expert operator so
is not as simple to organise in some departments, compared to CT
scan - especially after hours. I do not know how easy it would have
been to organise either test in this department. It is reasonable
that a CT scan will be performed first - it has a good chance of
detecting a range of other possible conditions that could be
causing acute abdominal pain such as diverticulitis, abscess or
even tumour. Neither CT nor ultrasound are reliable in diagnosing
appendicitis which [Mr A] also was found to have at surgery the
next day.
At this stage, [Mr A] was under the care of a surgical service
and I would defer to a surgical specialist to advise on the
appropriate tests (or otherwise) after the initial CT scan was
performed and found to be non-diagnostic. My comments were based
mainly on the absence of any indication in the ED notes of whether
an ultrasound was considered at all.
Appendix 3 - Independent advice from Dr Andrew Connolly
Thank you for requesting my advice on a major complaint received
by the Commissioner regarding the care of the late [Mr A]. I have
been supplied with a very detailed set of notes and scans. I have
read all the documentation supplied.
Professional Qualifications
I hold a Bachelor in Human Biology (BHB) University of Auckland
(1984) and a medical degree (MBChB) from the University of Auckland
(1987). I am a Fellow of the Royal Australasian College of Surgeons
(1994). I have formal post-fellowship training in colorectal
surgery in the United Kingdom. I am vocationally registered with
the Medical Council of New Zealand in General Surgery. I am a full
member of the Colorectal Surgical Society of Australia and New
Zealand.
The Counties Manukau District Health Board (CMDHB) employs me as
a full-time General & Colorectal surgeon. I am the Head of the
Department of General Surgery at CMDHB. I have previously served 12
months as the acting Clinical Head of Plastic & Reconstructive
Services at CMDHB.
I have had a formal 18-month period of clinical research
investigating the effects of, and treatment options for, severe
intra-abdominal infection and I have had a number of papers
published in peer-review journals on this and related topics. I
continue to be actively involved in clinical research, particularly
in the area of enhanced recovery after major abdominal surgery.
I have served on the Board of Basic Surgical Training,
Physiology subcommittee, for the Royal Australasian College of
Surgeons. I have served on the National Advisory Board regarding
the screening of at-risk groups for colorectal cancer. I provide
independent clinical advice as a Clinical Expert to the Accident
Compensation Corporation. I am on the Ministerial Advisory Group on
Clinical Leadership and Governance to the Minister of Health.
Conflict of Interest
I trained in General Surgery at the same time as [a] Consultant
Surgeon, Hutt Hospital.
Brief Clinical Summary
[Mr A] was a 35 year old man with significant intellectually
disabilities who presented acutely to Hutt Hospital [in early]
2008.
[Mr A] was noted by his care givers to be non-specifically
unwell. He appeared to have cool peripheries, was sweating, and had
a distended abdomen.
[Mr A] was assessed in the Emergency Department at Hutt Hospital
and ultimately admitted under care of the General Surgical
Department.
After a number of investigations including CT of the abdomen,
[Mr A] underwent an acute laparotomy at which time his gallbladder
was removed along with his appendix. Post-operatively, due to
concern about a possible bile leak, [Mr A] underwent an ERCP - this
was normal. [A week later], [Mr A] suffered a cardiac arrest and
died. A coronial autopsy examination revealed the cause of death as
bronchopneumonia.
The Advocate for the IHC (Mr B) has complained about a number of
aspects of the care [Mr A] received. I have read the complaint, the
supporting documentation, responses from the Hutt Valley DHB, and
the clinical notes.
The complaint is complex, and the Commissioner has asked 11
specific questions. I have endeavoured to avoid repetition wherever
possible.
General Standard of care by the Surgical Team
Overall in my opinion the surgical care given to [Mr A] was of a
high standard, but I believe he was not initially assessed in a
timely fashion and that intravenous fluid replacement was not
commenced as early as would be desirable in a patient with acute or
suspected intra-abdominal pathology. This criticism covers both the
Surgical Department and the Emergency Department and is discussed
more fully under point 2 below. However, it is very important to
note that I do not believe these initial delays made any
significant contribution to his death.
The time to theatre for the laparotomy was quite appropriate
given the CT scan did not show any need for an emergency operation.
The scan showed a possible bowel obstruction, but this does not
mandate an immediate operation - indeed many times such an
appearance would not result in an operation at any point in the
acute illness. There was no evidence of free air or free fluid. The
gallbladder was not markedly abnormal, and the appendix was not
obviously inflamed. In the initial hours, it is quite appropriate
for intravenous fluids with or without antibiotics to be used as
definitive treatment. I note that [Dr C] (Consultant Surgeon on
call) was contacted and the case discussed thoroughly with her. I
believe her decision making was of a high standard and that a
deferral of any operative intervention until a period of fluid
replacement had taken place was appropriate.
I believe the clinical team reacted appropriately in the
post-operative care - again, this is more fully covered below
(point 5).
Timeliness and Standard of Pre-operative Assessment
As noted above, I have concerns about the timeliness of the
initial ED and Surgical reviews. [Mr A] arrived in the ED at
approximately 0900 hours, but was not medically assessed until 1215
hours ([Dr G], Emergency Department). At that point a surgical
referral was made, but the admitting surgical registrar did not see
[Mr A] until 2130 hours. In the interim, [Dr G] handed care on to
his ED senior colleague, [Dr L]. At 1730 hours [Dr L] assessed [Mr
A]. It was only after the review by [Dr L] that IV fluids were
commenced. Once the surgical registrar, [Dr H], saw [Mr A], a CT
scan was arranged, as [Dr H] believed [Mr A] to be septic from an
unknown, but possibly intra-abdominal, source. Following the scan,
which raised a small bowel obstruction as a possible diagnosis, [Dr
C] (Consultant Surgeon on call) was contacted. A decision was made
to continue fluid rehydration and to keep a close clinical eye on
[Mr A] overnight. Should [Mr A] not be significantly better by
morning, a laparotomy was likely. [Mr A] was assessed medically at
least twice after the discussion with [Dr C]. In addition, regular
nursing observations were performed on the ward. [Dr C] reviewed
[Mr A] at 0745 hours and advised a laparotomy. Because of issues
surrounding the correct consenting procedure in a patient judged
not to be of a capacity to give informed consent, [Dr C] discussed
the case with two senior colleagues unrelated to the clinical care
of [Mr A]. The unanimous view of the senior staff was that [Mr A]
required acute surgery and the operation commenced later that
morning.
In my opinion, the decision-making regarding pre-operative
investigations and the timing of the surgery was appropriate. A
period of IV fluid resuscitation is usually very valuable in
patients who do not have a clinical indication to undergo immediate
surgery. Neither the clinical signs nor the CT scan showed an
unequivocal indication for immediate surgery. I therefore believe
[Dr C's] decision to delay any surgery until the morning was very
appropriate. I believe the timing of surgical review after
the initial surgical review at 2130 was appropriate, but I do not
believe [Mr A] should have waited from 1215 hours (the time of
referral) until 2130 hours for the first surgical review. However,
there is no evidence at all that this delay contributed to [Mr A's]
death.
Similarly, the delay in the first medical assessment in the ED
was well outside the guideline times. This again is regrettable,
but in my opinion, did not in any way contribute to [Mr A's]
death.
I note the apparent busy state of the ED on the day in question
along with the ED staffing levels. I believe the staff in the ED
were working in an under-resourced clinical environment that day. I
have made further comment in point 10.
Despite the delays, I do not believe [Mr A's] life was put at
risk by the time he spent waiting for reviews and decisions made
prior to his operation. There is no evidence he aspirated during
his time in the ED. There is no evidence earlier assessment or the
earlier introduction of IV fluids would have influenced the
eventual outcome. But the time taken to see and instigate treatment
was too long from a "Quality" rather than clinical safety
perspective.
Standard of Surgery
[Mr A] had an appropriate operation - exploratory at first, then
targeted to the two most important organs - the gallbladder and the
appendix. Whilst the appendix was visibly normal, the decision to
remove it was appropriate given the diagnostic uncertainty. The
gallbladder was also appropriately removed. I note the operation
record is both detailed and thorough and of a standard expected of
a consultant surgeon. I also note the Coroner found no evidence of
any "complications" in the surgical sites.
Adequacy of Clinical Observations
Preoperative: [Mr A] had a set of observations performed and
documented at 0910 hours - this is well within acceptable
timelines. However, after these initial recordings, the next set
recorded was at 1200 hours. It can be argued that a more regular
set of recordings should be obtained in an acutely unwell patient,
but the timeline is not poor. There are no nursing notes for the
period following triage at 0910 to the start of the next nursing
shift. This is not acceptable and I note the comments by [the]
Charge Nurse (ref. page 086). I agree with [the] C/N that the
standard of record keeping by Nurse [Mr F] was substandard.
However, in my opinion this made no contribution to [Mr A's] death.
I am unable to find any record written by [Dr G] referring to the
1215 assessment. I interpret some of the comments in the notes as
suggesting the record may have been purely electronic and therefore
"merged" with the ED discharge paperwork after Surgery accepted [Mr
A] as an in-patient. Whatever the issues may have been, in my
opinion there should be a hand written note especially on acute
patients. The lack of one creates significant problems with
thorough and effective clinical communication.
Post-operative: These appear to have been regularly and
appropriately performed. The documentation is clear and concise. I
note particular emphasis was placed on oxygen saturation levels -
this indicates an awareness of the potential for a person after
abdominal surgery and with an intellectual disability to an
increased risk of respiratory compromise.
Standard of Post-operative Care
In my opinion the standard of post operative care was high. [Mr
A] was clearly noted to be at increased risk of complications due
to his intellectual disabilities. The staff (both medical and
nursing) regularly reviewed him. I believe the surgical staff acted
appropriately when the possibility of a bile leak was raised. The
ERCP was an appropriate test. Fluid and antibiotic use appear to be
appropriate and within accepted guidelines.
There is a detailed record of the nursing cares, particularly
the turning of [Mr A] on a regular and frequent basis. I believe
this also indicates a heightened awareness of staff to the issue of
intellectual disability and recovery from major surgery.
Documentation
The documentation of the surgical team was of an acceptable
standard.
Communication with Care Givers
The hospital has detailed a number of times where hospital staff
spoke with and updated the IHC caregivers. I do not feel I need
reach a "judgement" on this issue given that none of the IHC staff
appear to have been legally entitled to information - none were [Mr
A's] legal guardian. Under the Privacy guidelines that govern
hospital staff and the dissemination of information, I do not
believe any greater degree of information should have been passed
to IHC staff, nor do I believe the transfer of greater information
was required to allow the hospital staff to care for [Mr A].
Informed Consent Procedures
In my opinion the issue raised in regard to who had the legal
responsibility and right to grant consent for any invasive
procedure had no part to play in [Mr A's] death. Given I believe
the timing of the operation was appropriate and that [Dr C] has
stated she was unable to identify any one via IHC who had a legal
right to act for [Mr A], [Dr C] did what is well established in the
Profession - she sought the opinions of at least two colleagues
unrelated to the direct care of the patient. The operation took
place soon after the decision was made to operate. The findings at
surgery were not indicative of sepsis in the abdomen that
had gone untreated for an inappropriately long time. In summary,
the consent issues did not significantly delay [Mr A's] arrival in
the operating theatre, nor did any issue in obtaining consent
contribute to his death. There is no evidence at all that [Mr A]
aspirated in the pre-operative period.
I believe the DHB had appropriate policies and guidelines in
place. The "Informed Consent" guide, "G12-Informed" of May 2006, is
clear in stressing the need to discuss a case with a senior
colleague if the patient is incapable of giving consent. I also
note the "Form for Incompetent patients", dated April 2005. This
seems appropriate, although specific reference to it in the section
of the G-12 paper relating to "Unable to Give Consent" would have
alerted staff to the Form for Incompetent patients. A written
record of consent is generally expected and is sensible to obtain
in all but the most immediate operations. But as noted in point 9,
I cannot personally locate a completed consent form.
Changes in Policy and Process made by HVDHB
I believe the DHB has made positive improvements in some areas
in response to the complaint about [Mr A's] care. I specifically
refer to the ED Staffing contingency plan and to the increase in
medical staff numbers in the ED. These steps should ensure greater
access to medical care in a timely fashion. I believe the ED senior
nursing staff responded appropriately to the issue of poor initial
nursing documentation.
I cannot find the written informed consent sheet (the Form for
Incompetent patients) in the notes supplied to me. There is a
standard consent form present with [Mr A's] patient label attached,
but it has no other documentation on it (ref page 180). As noted in
point 8, I believe specific direct linkage to this sheet in the G12
document on informed consent would be sensible.
I can find no specific reference to any other changes the HVDHB
has made. I would advise the DHB to review the acute Surgical
registrar role and policy in relation to the time taken to see [Mr
A] in the ED. As with ED medical staff, it is apparent that the
surgical registrar was "busy elsewhere" for much of the day, but
the Department of General Surgery needs to have a contingency for
this problem. Whilst I find no evidence to suggest the time waiting
for the first surgical review contributed to [Mr A] death, the time
was nonetheless excessive.
10 & 11. General Comments
[Mr A] died of aspiration pneumonia. He was at risk of this due,
amongst other things, to recent major abdominal surgery and
intellectual impairment. However in my opinion his care was of an
acceptable standard and whilst there were delays in the initial
assessment and problems with poor documentation in the ED, neither
of these factors contributed to his death.
In my opinion, [Mr A] was treated aggressively in the
post-operative period and attempts to resuscitate him were
correctly carried out and documented. I do note there is reference
to some comments regarding quality of life, but there is no
evidence that staff reduced the level of expected care or clinical
standards on the basis of [Mr A's] intellectual impairment.
I believe the HVDHB has responded appropriately to the staff
issues in the ED. I believe the DHB needs to confirm it has robust
policies in place regarding the availability of timely clinical
review from the in-patient acute services including General
Surgery. The balance between workload demands and realistic
staffing models is often difficult to achieve, but contingencies
for situations where workload exceeds the designated staff levels
need to be in place.
I trust this opinion will be of assistance to the Commissioner.
Please do not hesitate to contact me if required.
[1] Mr A had a laparotomy (exploration
of the abdomen), an appendicectomy (removal of the appendix) and a
cholecystectomy (removal of the gall bladder).
[2] A pneumonia
involving inflammation of the lungs that spreads from and after
infection of the bronchi.
[3] IHC is a provider of services for
people with intellectual disabilities. Since 2005, residential
support services have been provided through IHC's provider arm,
IDEA Services Limited.
[4] Triage 3 categorisation meant that
he should have been seen by a doctor within 30 minutes of
presentation.
[5] Ms D and Ms E were relieved by Ms K
at 11.30am. Ms D returned to the hospital at about 3.00pm and Ms E
at about 8.30pm.
[6] See Appendix 1 for record of ED
observations.
[7] Dr G's notes were recorded
electronically in the ED Electronic Discharge Summary. The notes
appear under the name of another clinician, as the last authorised
person accessing an unfinished document. Although Dr G did not
recall his contact with Mr A, he considered that as the notes are
written in a format consistent with his own, it is "more likely
than not" that he was the physician responsible for Mr A's initial
care in ED.
[8] See Appendix 1.
[9] Latex sheath: part of an external
catheter.
[10] Elastic stockings worn to prevent
a thrombosis.
[11] Right 7 outlines the right to make
an informed choice and give informed consent. Right 7(4) concerns
the provision of services where a consumer is not competent to make
an informed choice and give informed consent.
[12] In my provisional findings, I
noted that there were no notes from ED nursing staff in relation to
the catheter insertion. In its response, Hutt Valley District
Health Board advised that this was not correct. On further enquiry,
it transpired that a page of the ED documentation originally
provided to HDC, and subsequently sent to our experts, was
incomplete. The DHB explained that the nurse performing the
catheterisation had documented this in the ED notes, but that this
occurred after the notes had been copied in preparation for Mr A's
transfer to a ward. It was the copy without the
information about the catheterisation and the nasogastric tube that
was included in the notes that later went to the ward with Mr
A.
[13] The partition between the
nostrils.
[14] A specialised technique used to
view and/or treat the pancreas, gallbladder, and bile ducts.
[15] A drink used when nutritional
requirements are not being met through ordinary food.
[16] A fleet enema is a manufactured
enema formula.
[17] The DHB referenced the following
articles as evidence of this: "Long-Term Outcomes of ICU-Acquired
Neuromuscular Abnormalities" (Pedro A. Mendez-Tellez and Todd
Dorman) Contemporary Critical Care, July 2005, Vol.3,
No.2.; "Critical illness polyneuropathy and myopathy in patients
with acute respiratory distress syndrome" (Sven Bercker, Steffen
Weber-Carstens, Maria Deja, et al), Crit Care Med 2005,
Vol.33, No.4.; "Characteristics and outcomes for critically ill
patients with prolonged intensive care unit stays" (Claudio M.
Martin, Andrea D. Hill, Karen Burns, Liddy M. Chen) Crit Care
Med 2005, Vol.33, No.9.
[18] The DHB advised that the usual
number of patient presentations was about 100 per day.
[19] See 07hdc14539 (12 December
2008).
[20] See 07hdc10767 (25 September
2008).
[21] Ardagh, M. & Richardson, S.
(2004). Emergency department overcrowding - can we fix it?
NZMJ,
117 (1189).
[22] See 05hdc11908 (22 March
2007).