Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

1. The Coroner’s Office referred a complaint to HDC from Ms A regarding the care provided to her late mother, Mrs B, by Health New Zealand|Te Whatu Ora (Health NZ) Whanganui and Health NZ Capital, Coast and Hutt Valley. Ms A raised concerns that inadequate communication and coordination of care between the two hospitals led to errors in the dosage of her mother’s dexamethasone.[1]
   
   
2. Mrs B had a medical history of rheumatoid arthritis, which had been managed by methotrexate[2] since at least 2016, and type 2 diabetes, which was controlled by diet. In late June 2021 Mrs B was diagnosed with a brain tumour. Sadly, following multiple hospital admissions from June through to August 2021, Mrs B passed away. I offer my sincere condolences to Mrs B’s family for their loss.

June 2021 admission — Public Hospital 1

3. On 29 June 2021 Mrs B was admitted to Public Hospital 1’s Emergency Department (ED) with left-sided weakness, sudden onset of confusion, and slurring of words. A head CT scan showed a large extra-axial[3] mass indicative of a meningioma,[4] which was confirmed by a subsequent MRI scan. A resident medical officer (RMO) recorded that she discussed Mrs B’s case with a neurosurgical registrar, who advised starting a 4mg dose of dexamethasone twice daily and pausing the administration of methotrexate.
   
   
4. Mrs B was seen by senior medical officer Dr C the next morning (30 June 2021). Dr C recorded that he discussed the findings of the CT scan with Mrs B’s family and prescribed a dexamethasone dosage of 8mg twice daily. This dosage was then increased to 16mg BD[5] on Mrs B’s drug chart the same day. No reasoning for either of the dosage increases was documented in the clinical records, and the new dosage of 16mg BD was carried over throughout Mrs B’s admission at Public Hospital 1, and it continued on Mrs B’s discharge on 2 July 2021.
   
   
5. Another RMO told HDC that he was responsible for charting Dr C’s direction under supervision, and that the change in dosage was recorded to reflect Dr C’s decisions, which were made at Mrs B’s bedside. The RMO told HDC that the decision to continue the 16mg BD dose upon discharge reflected Dr C’s wish to review Mrs B’s condition and this dosage following a multidisciplinary meeting (MDM).
   
   
6. Dr C told HDC that he decided to add in high-dose pulses of dexamethasone as there were no ‘real improve[ments]’ in Mrs B’s clinical condition on the initial 4mg dosage of dexamethasone. Dr C said that acutely high-dose pulsed dexamethasone is often used to recover neurological function, and clinically this was more important to Mrs B than the risk of side effects. Dr C told HDC that Mrs B made a full neurological recovery after this increased dose, which provided the opportunity for Mrs B to be referred to Public Hospital 2 for potential surgery.

12 July 2021 neurosurgery clinic — Public Hospital 2 (Health NZ Capital, Coast and Hutt Valley)

7. Mrs B was subsequently seen by neurosurgeon Dr D at Public Hospital 2 on 12 July 2021. At this stage,[6] Mrs B would have been taking 32mg of dexamethasone daily for 10 days.
   
   
8. Dr D noted in his clinic letter that he discussed the scan and MDT findings with Mrs B and her family, as well as options for surgery and radiation therapy. Mrs B did not want to pursue surgery at this time and preferred to explore the option of radiotherapy. Dr D also recorded that Mrs B could restart her methotrexate and wean her steroids until she was to be reviewed by the radiation oncologists. On 13 July 2021 Mrs B was discharged with a weaning regimen[7] and a reduced dexamethasone dosage of 4mg QID.[8]
   
   
9. Dr D told HDC that ‘[i]t is not unheard of’ for patients to be on high-dose steroids up to 32–64mg a day for short durations to control cerebral oedema,[9] but the normal dosage would be 4mg QID (ie, 16mg a day). Dr D said that Mrs B’s rheumatoid arthritis and long-term methotrexate use would have caused an immunocompromised state, and the unavoidable addition of dexamethasone would have predisposed Mrs B to raised levels of blood sugar and infection.
   
   
10. Dr D told HDC that as Mrs B did not want neurosurgery, she was then discharged to Public Hospital 1 and therefore, the Public Hospital 2 staff did not have control over how Mrs B was managed subsequently in Public Hospital 1. In response to the provisional report, Health NZ Capital, Coast and Hutt Valley stated that a discharge summary was completed, and information was provided to the referring hospital, and it was up to Public Hospital 1’s team to contact Public Hospital 2 with any queries.

14 July 2021 admission — Public Hospital 1

11. On 14 July 2021 Mrs B was re-admitted to Public Hospital 1 with lower extremity weakness and high blood-sugar levels. Dexamethasone 16mg BD was administered, with no documented reasoning for the increased dose.
    
    
12. On 15 July 2021 Mrs B was seen by consultant Dr E, who recorded that dexamethasone was affecting Mrs B’s diabetes and lower limb weakness. However, Dr E made no changes to the dexamethasone dosage. Dr E considered that Mrs B’s high blood pressure was being caused and/or worsened by dexamethasone, and that seemingly Mrs B’s lower extremity weakness was a result of the brain tumour and steroid-induced myopathy,[10] which is a common and expected side effect. Dr E told HDC that Dr D’s clinic letter was unavailable to her at the time, so she was unaware that the dexamethasone dosage had changed, and therefore she had relied on the dosage as set out in the discharge plan of 2 July 2021.
    
    
13. A medicine reconciliation was initiated by a pharmacist on 15 July 2021 after discrepancies were identified between the 2 July 2021 discharge summary and the 14 July 2021 doses. The medicine reconciliation noted a weaning regimen for dexamethasone consistent with Dr D’s regimen set from 12 July 2021 and starting methotrexate from 19 July 2021. Despite these notes, 16mg BD doses of dexamethasone were administered until 18 July, after which dexamethasone was re-prescribed at 4mg TDS from 19 July until discharge. There is no documented reasoning behind these changes.
    
    
14. Dr E told HDC that the reason why the dosage was not changed until 18 July 2021 was because although the medicine reconciliation form was completed on the evening of 15 July 2021, her team were not alerted to the final dose changes until 18 July 2021.
    
    
15. On 19 July 2021 a physiotherapist completed an incident report as Mrs B had fallen to the ground after becoming fatigued and having experienced lower blood pressure after mobilising. An hour later, Mrs B was assessed by an RMO, who recorded that this episode of low blood pressure seemed to be due to anti-hypertensive medication. On 20 July 2021 the RMO discussed Mrs B’s fall and discharged Mrs B with an immediate stop to the anti-hypertensive medications. Mrs B was also discharged with a dexamethasone weaning regimen[11] (intended to end on 9 August 2021).
    
    
16. Ms A told HDC that she was shocked that her mother was discharged on 20 July 2021 despite having experienced a fall and having limited mobility. Dr E told HDC that Mrs B was stable from her admission on 14 July until 19 July, her mobility was improving with assistance, and no new issues or concerns were raised or reported at this time. As Mrs B had improved clinically, there was ‘nothing else’ that the hospital could do for her, and therefore she was medically cleared for discharge after the MDM review. Regarding the fall on 19 July, Dr E told HDC that this was considered to have been an episode of hypotension[12] due to anti-hypertensive medication, and that when reassessed on 20 July 2021 Mrs B was stable, normotensive,[13] and afebrile.[14]
    
    
17. Ms A told HDC that for the next few days the family tried to support Mrs B, but she collapsed twice, and on one occasion they needed to call an ambulance.
    
    
18. On 26 July 2021 Mrs B’s GP made a home visit at Ms A’s request. The GP told HDC that at this visit he considered that Mrs B’s diabetes had been exacerbated by the dexamethasone but at the time of the home visit was well controlled, and Mrs B’s rheumatoid arthritis was a ‘perpetual concern’ for her.

1 August 2021 admission — Public Hospital 1 and Public Hospital 2

19. On 1 August 2021 Mrs B was admitted to Public Hospital 1’s ED via ambulance. She had experienced a general decline in the past three days, including an ulcerated mouth and lethargy. Mrs B was transferred to the General Medicine ward with a plan to hold her methotrexate until this was discussed further with the Neurosurgery Department, but to continue her dexamethasone dosage as planned. A medicines reconciliation form dated 2 August 2021 noted a reducing dose of dexamethasone of 4mg OD until 3 August, then 2mg from 4 August for 5 days and then a complete stop.
    
    
20. On 2 August Dr E assessed Mrs B as stable and planned to transfer her to Public Hospital 2 the next day. On the evening of 2 August 2021, an RMO reduced the dexamethasone dosage to 2mg OD after receiving a call from a neurosurgery registrar in Public Hospital 2.
    
    
21. On 3 August Mrs B was transferred to Public Hospital 2 for ongoing care. Mrs B was admitted to Public Hospital 2 ICU a few days later after she developed fevers and increased oxygen requirements. Subsequently, Mrs B passed away due to pneumocystis pneumonia[15] thought to be caused by immunosuppression in conjunction with meningioma treatment.

Subsequent actions

22. On 13 August 2021 Health NZ Capital, Coast and Hutt Valley reported a medication event regarding the dosage changes in dexamethasone for Mrs B during the care period June 2021 to August 2021. Health NZ Capital, Coast and Hutt Valley concluded that there was a ‘significant discrepancy’ between the dose advised by Public Hospital 1’s neurosurgical team, and the dose prescribed by the team on 2 July 2021. Health NZ Capital, Coast and Hutt Valley noted that the medication had been weaned in response to this discrepancy.
    
    
23. After receiving notification from Health NZ Capital, Coast and Hutt Valley, Health NZ Whanganui filed an incident report on 21 September 2021 regarding the potential medication error. The incident report noted that on 1 July 2021 Dr C had made an intentional increase from 4mg BD to 8mg BD after he had assessed Mrs B and reviewed her imaging. As a result of the findings in the report, Health NZ Whanganui noted that the change to be implemented was to ensure that medical staff document the rationale for increasing from recommended dosages in patient notes.
    
    
24. Health NZ Whanganui also conducted a chart review on 27 September 2021, which confirmed that the dose of dexamethasone had been increased to 16mg BD intentionally on 30 June 2021, and that Mrs B’s symptoms had improved as a result. This dose continued for 12 days, when Mrs B was already immunocompromised due to the methotrexate she was taking to treat her arthritis.
    
    
25. The review accepted that no rationale was documented for the 30 June increase but that the relevant clinician stated that the increase was to ‘manage the significant cerebral oedema visible on CT scan’. The review also noted that the rationale for the further increase on 2 July was not documented, and that the relevant clinician cannot recall prescribing a further increase. The review again recommended that the rationale for changes to medication dosages should be documented in the clinical record, and that the appropriate outcome measure would be an audit (to be reviewed in March 2022).

Further information

26. Public Hospital 1’s Medical Procedure in place at the time states:

‘The prescribing of medicines is in accordance with best practice treatment principles for the patient’s condition with awareness of contraindications, allergies, organ function and medicine interactions. The reason for prescribing a medicine is documented in the patient’s health record.’

27. My independent clinical advisor, geriatrician Dr Nigel Millar, advised that for dexamethasone, the New Zealand Formulary recommends referring to a local protocol or initially 8–16mg by injection then 4–16mg daily in one to four divided doses, with an added caveat that higher doses may be necessary under specialist review. The New Zealand Formulary states that the dose should be adjusted to response, and to use the lowest dose for the shortest possible time.
    
    
28. Dr Millar also advised that high-dose steroids suppress the immune system and make infections more likely and potentially more severe. Steroids may also mask the symptoms, signs, and laboratory changes of serious infection associated with steroids.
    
    

Independent clinical advice

29. Dr Millar advised that the care provided to Mrs B was ‘less than ideal’ in several respects and affected her adversely. He considered that some of the problems resulted from poor coordination of care between Public Hospital 1 and Public Hospital 2.
    
    
30. Dr Millar identified the following departures from standards of care for Health NZ Whanganui:

1. 1. The prescribed steroid regimen during Mrs B’s initial admission (29 June to 2 July 2021) — moderate departure.
   2. The 2 July discharge plan and associated dosage of dexamethasone with no reduction plan — severe departure.
   3. The quality of documentation regarding clinical decisions at multiple points of Mrs B’s care — moderate departure.
   4. The level of communication and consultation between Health NZ Whanganui and Health NZ Capital, Coast and Hutt Valley regarding prompt communications in urgent or critical situations — moderate departure.
   5. The reversion and continuation of a high 32mg dosage of dexamethasone at the 14 July 2021 admission — severe departure.
      
      

Responses to provisional decision

31. Ms A was provided with an opportunity to comment on the ‘information gathered’ section of the provisional decision. She confirmed that she had no further comments to make.
    
    
32. Health NZ Whanganui was provided with an opportunity to comment on the provisional decision. Health NZ Whanganui confirmed that it had no further comments to make. It also provided a copy of its recent audit on documentation for changes in medication and confirmed that a quarterly reminder has been set for this audit.
    
    
33. Health NZ Capital, Coast and Hutt Valley was provided with an opportunity to comment on the provisional decision. Information provided by Health NZ Capital, Coast and Hutt Valley has been incorporated into this report where relevant.
    
    

Decision

34. Specifically, between June and August 2021 Mrs B’s care was affected by several medication errors in her dosage of dexamethasone, as well as a lack of communication, consultation, and documentation regarding discharge plans and follow-up actions. Although it is difficult to make a clear finding regarding the connection of these actions to Mrs B’s passing, it is clear that overall, Mrs B did not receive care of an appropriate standard.

Health NZ Whanganui — breach

35. On 30 June 2021 Dr C prescribed a dexamethasone dosage four times the dosage recommended by a neurosurgical registrar, without any further consultation with the prescribing neurosurgical team. This high dosage was continued throughout Mrs B’s admission and discharge, until she was seen again on 12 July 2021, again with no evidence of consultation occurring with the neurosurgical team.
    
    
36. I am critical of Health NZ Whanganui’s lack of effective communication and follow-up to ensure that Mrs B was being cared for appropriately during her admission and upon discharge, and that it was unclear who was leading and coordinating Mrs B’s care. There is no documented evidence that advice was provided to Mrs B’s family or her GP about following up regarding the markedly high dexamethasone dosage (and its subsequent side effects and risks). It is also unclear what actions (if any) were considered following the MDM, which Dr C told HDC he was waiting on before making any changes to the dexamethasone dosage. Dr Millar advised that it is the responsibility of the prescribing physician to ensure that a plan is in place, or to clearly delegate and communicate the responsibility to another clinician (in this case Mrs B’s GP). I accept this advice.
    
    
37. There are also clear gaps in accessibility of documentation between the hospitals and even between teams within the same hospital, which directly contributed to inappropriate clinical decisions based on incomplete information. Dr E told HDC that she did not have access to Dr D’s discharge summary for 13 July 2021, and that her team was not informed of the 15 July medicines reconciliation until 18 July. This meant that Dr E relied on information from 2 July 2021 to revert to the exceptionally high dosage of dexamethasone, instead of Dr D’s intended weaning regimen. I am critical that Health NZ Whanganui did not have an effective clinical portal system to avoid these clear missed opportunities where key documents needed to be accessed and considered but were unavailable, meaning that incorrect clinical decisions were made.
    
    
38. I also consider that poor record-keeping practices contributed to ineffective communication and co-ordination of Mrs B’s care, noting that the rationale for key decisions such as dosage changes were not documented on multiple occasions, and it was unclear from the discharge plans what (if any) information was provided to Mrs B, Mrs B’s family, and Mrs B’s GP about dexamethasone dosage and appropriate follow-up actions.
    
    
39. Having carefully reviewed all the information above, I consider that Health NZ Whanganui breached Right 4(5) of the Code of Health and Disability Services Consumers’ Rights[16] in its provision of care to Mrs B due to inadequate communication and consultation, ineffective clinical portal systems, and poor record-keeping practices, all of which did not support the coordination of care between and within the hospitals.
    
    

Health NZ Capital, Coast and Hutt Valley — educational comment

40. Dr D restarted Mrs B on methotrexate upon discharge on 12 July 2021, contrary to the discharge advice set out by Health NZ Whanganui on 2 July 2021, and the rheumatologist advice dated 1 July 2021. There is no evidence that Health NZ Whanganui and/or the rheumatologist was consulted in making this decision. I do note, however, that the reason for restarting the methotrexate is documented clearly in Dr D’s clinic letter to Mrs B’s GP, a copy of which was to be sent to the rheumatologist. I remind Health NZ Capital, Coast and Hutt Valley of the value in consulting with specialists and initial prescribing clinicians before making any critical decisions on dosage changes, particularly in cases such as this, where both dexamethasone and methotrexate are considered immunosuppressive medications.
    
    
41. Information sharing and transfer of care is a two-way relationship. I consider that Health NZ Capital, Coast and Hutt Valley also holds a level of accountability/responsibility in ensuring effective coordination of care with Health NZ Whanganui and ensuring that all documentation was sent and received appropriately. I encourage Health NZ Capital, Coast and Hutt Valley to work with Health NZ Whanganui proactively to ensure that effective information sharing and co-ordination of care is taking place at all times.
    
    

Recommendations and follow-up actions

42. I recommend that Health NZ Whanganui:

1. 1. Provide a written apology to Mrs B’s family for the deficiencies outlined in this report. The apology is to be sent to HDC within three weeks of the date of this report, for forwarding to Mrs B’s family.
      
      
   2. Develop and conduct an audit to evaluate compliance of the quality of documentation standards in clinical decision-making regarding medication dosage. Noting the findings from the first round of the audit, please provide HDC with an action plan of corrective actions to be implemented, and a further copy of the findings for the next quarterly audit, within three months of the date this report.
      
      
   3. Work collaboratively with Health NZ Capital, Coast and Hutt Valley to review its standards and guidelines regarding inter-hospital information sharing, co-ordination of care, and clinical portal access, and develop a policy on expected standards of inter-hospital information sharing, and a documented process for expectations regarding regional clinical portal access. A copy of these policies and processes is to be provided to HDC within six months of the date of this report.

43. In light of the findings in this report, I recommend that Health NZ Whanganui and Health NZ Capital, Coast and Hutt Valley consider a review of current regional guidelines on the use of dexamethasone for treatment of cerebral oedema associated with tumour, in partnership with specialist services and regional clinical services. If no such guidelines exist, I recommend that Health NZ consider developing regional guidelines for dexamethasone dosage in this context. An update regarding the progress of this work is to be provided to HDC within three months of the date of this report.
    
    
44. A copy of this report with details identifying the parties removed, except Health NZ Whanganui, Health NZ Capital, Coast and Hutt Valley, and my clinical advisor, will be sent to Health New Zealand|Te Whatu Ora and Te Tāhū Hauora|Health Quality and Safety Commission and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

  

 

Carolyn Cooper

Deputy Health and Disability Commissioner

 

Appendix A: Summary of dexamethasone dosage changes

Date	Dosage	Hospital
29 June 2021	4mg BD	Public Hospital 1
30 June 2021	8mg BD	Public Hospital 1
30 June 2021	16mg BD	Public Hospital 1
12 July 2021	4mg QID	Public Hospital 2
13 July 2021	Wean 4mg QID 4mg TDS 4mg BD 4mg OD 2mg OD	Public Hospital 2
14 July 2021	16mg BD	Public Hospital 1
18 July 2021	4mg TDS	Public Hospital 1
20 July 2021	Wean 4mg TDS 4mg BD 4mg OD 2mg OD	Public Hospital 1
1 August 2021	4mg OD	Public Hospital 1
3 Aug 2021	2mg OD	Public Hospital 2

                                                                                                                         

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