1. In January 2022, the Health and Disability Commissioner (HDC) received a complaint from Mrs A about the standard of care provided to her late husband, Mr A, at Waikato Hospital over a two-day period in December 2019. The complaint was made after Mr A was found unconscious after leaving the Coronary Care Unit (CCU) having fallen down a stairwell. Mrs A is concerned about the standard of diabetes care provided to Mr A and the delay in staff recognising his absence from the CCU.
   
   

Information gathered

Emergency Department

2. Mr A, aged 79 years at the time, had multiple comorbidities, including an extensive cardiac history, longstanding memory loss, dementia, mild cognitive impairment with a Montreal Cognitive Assessment (MoCA)[1] score of 24/30, and insulin-dependent type 2 diabetes. An adverse event review (AER) completed by Health New Zealand | Te Whatu Ora Waikato (Health NZ) noted that Mr A was independent with his activities of daily living. In contrast, Mrs A stated that he had reduced mobility and required monitoring due to his dementia.
   
   
3. At 3.10am on Day1 December 2019, Mr A presented to the Waikato Hospital Emergency Department (ED) with chest pain. He was accompanied by Mrs A. Mr A had a working diagnosis of non-ST-elevated myocardial infarction (a type of heart attack). At the time of triage, a nurse recorded that Mr A’s history included type 2 diabetes. However, the clinical notes do not record whether Mr A was on insulin or other medications for his diabetes. Mr A’s blood glucose level (BGL) was measured as 15.2mmol/L[2] (high) at 3.10am, but there is no record of further BGL testing in the ED.
   
   
4. Mrs A told HDC that they brought Mr A’s diabetic kit, diabetic record book, and medications with them to the hospital. Mrs A said that Mr A’s BGL was not measured, and ED staff did not give him insulin in the morning. Mrs A stated that she queried this with an ED nurse, but the nurse did not check Mr A’s BGL, did not get the insulin charted, and did not document this conversation. Mrs A decided to test Mr A’s BGL, and she gave him his insulin injection and noted this in his diabetic record book.
   
   
5. The clinical notes contain limited documentation by the ED nurses. The notes include a triage summary, vital sign measurements, and two very brief notes[3] in the ED chart. However, there is no documentation of the care Mr A received, and little evidence of a nursing assessment having occurred. There is no mention of any tasks undertaken, such as taking a BGL, or whether cardiac monitoring occurred. However, the blood test results indicate that a sample was taken at 3.30am, and the triage summary indicates that an ECG was taken. Several documentation entries made by the ED staff are illegible.

CCU

6. Mr A was transferred to the CCU (CCU3)[4] at 2.30pm on 29 December 2019. There is minimal documentation around the information that was handed over to CCU staff. The next BGL check occurred at 5.37pm and was noted to be 6.8mmol/L. Thereafter, regular BGLs were recorded pre-meals, and insulin was administered in accordance with Mr A’s prescription. Nursing notes record that Mr A had diabetes, that he was to have a diabetic diet, how often his BGLs were to be tested, and that he was on insulin.
   
   
7. Despite Mr A having presented as orientated and stable while he was in the ED, clinical records indicate that around 11pm he was unsettled with possible confusion. The AER notes that a Confusion Assessment Method (CAM)[5] is required when there is a change in behaviour. However, this did not occur. At 1.30am on Day2 December 2019, Mr A was noted to be settled and sleeping well.
   
   
8. At 5.30pm on Day2 December 2019, Mr A’s BGL was 5.3mmol/L, and insulin was administered. Following this, Mr A had his dinner, and at 9.30pm a further BGL was taken, which returned a level of 4.4mmol/L. Mrs A told HDC that Mr A would be unsteady and his cognitive ability would decline at a reading as low as 5mmol/L. Health NZ said that this reading was within the lower range, and its Diabetic Emergencies Hypoglycaemia[6] guideline (dated 2017) requires a carbohydrate snack to be given when the BGL is under 4mmol/L.
   
   
9. Mr A expressed concern to the afternoon CCU nurse about having a BGL of 4.4mmol/L. Health NZ said that the nurse told Mr A that she would get him a drink and a sandwich, but as there were no sandwiches in the CCU3 fridge, the nurse went to look in the CCU2 fridge. Health NZ said that when the nurse returned to the room at 9.44pm, Mr A was not there. The AER notes that if food had been available in the CCU3 fridge, this would have enabled the rapid provision of food to Mr A and reduced the risk of him leaving the CCU.
   
   
10. As Mr A was not in his room at 9.44pm, the nurse left the food on his bedside cabinet and returned 10 minutes later. At this point, Mr A was still not in his room, and the nurse assumed that he was in the toilet, as this was occupied. Health NZ said that the nurse’s assumption reduced the recognition of the necessity to sight Mr A, and the escalation of his missing status was not triggered. Health NZ stated that the nurse understands that the assumption she made was an error in judgement and resulted in a delay in escalating a search. In addition, the Diabetic Emergencies Hypoglycaemia guideline requires that the BGL is retested 10 minutes after the intervention, but this did not occur.
    
    
11. Clinical notes record that the nurse checked Mr A’s room again at 10pm and, because he was still not in his room, she tried to call Mrs A to ask whether Mr A had a mobile phone. The call to Mrs A was not answered. The nurse then tried to find Mr A by looking outside CCU3 and downstairs. After this, she informed the nurse coordinator and rang hospital security to try to locate Mr A. The exact time of informing the nurse coordinator and hospital security is not known. In response to the provisional report, an immediate family member of Mr A said that there was a delay in notifying the nurse coordinator and security.
    
    
12. Mrs A told HDC that Mr A’s mobility was not good, and he became unsteady when he experienced hypoglycaemia. Waikato Hospital CCTV footage showed Mr A standing in front of a vending machine at 10.27pm. Mrs A said that he would have had to move from one end of the ward, past the nurses’ station, past the reception area to the doorway, where he would have had to press the hand-activated button to exit. CCTV footage also shows that 11 people walked past Mr A, seven of whom appeared to be staff. However, staff did not appear to check on Mr A.
    
    
13. Health NZ said that it recognises that people with dementia have a higher propensity to delirium when outside their normal environment and routines. The CCU environment was busy on Day2 December 2019, and this may have created some disorientation for Mr A.
    
    
14. The AER notes that the CCU is an open unit, and that after 8pm, the electronic doors are locked. Exiting the ward areas requires hand activation of a wall button, which unlocks the door. At the end of CCU1 and CCU3 there are double fire doors that are not alarmed on opening. The AER notes that it is not uncommon for staff to use the CCU3 fire door egress and stairwell to go to the cafeteria. After this event, this door was checked and found not to be locked, allowing entry from the outside into CCU3. The AER notes that patients are free to move around within the unit, and they are asked to notify the nursing team if they wish to leave the unit. The AER found that there was a lack of signage and visual reminders to patients and family regarding notification to staff if they were leaving.
    
    
15. At 11.01pm, Mr A was found unconscious on the stairwell past the fire doors. A cardiac arrest call was put out, and cardiopulmonary resuscitation (CPR) was started. Mr A’s BGL was noted to be 1.8mmol/L. Sadly, Mr A died at 11.22pm.
    
    
16. Mrs A is concerned that Mr A was missing from the ward for 55 minutes before a search was undertaken, and it was not until 76 minutes after he left CCU3 that he was found.

Responses to provisional report

17. Mrs A and an immediate family member of Mr A were provided with the opportunity to comment on the ‘information gathered’ section of the provisional report. Both members of Mr A’s family reiterated that Health NZ failed to keep Mr A safe. The immediate family member said that staff disregarded family input into the treatment plan and the insulin record book, which showed Mr A’s previous insulin levels. In addition, the immediate family member said that there were consistent indicators of decreasing blood sugar levels over the course of Mr A’s admission, which should have resulted in a medical review. Other comments have been incorporated elsewhere in the report, including Appendix B.
    
    
18. Health NZ was provided with the opportunity to comment on the provisional report. Health NZ’s comments have been incorporated within this report as relevant.
    
    

Clinical advice

19. Independent clinical advice was received from registered nurse (RN) Marion Picken (Appendix A). RN Picken noted that the standard of cardiac management was acceptable. However, she noted the following departures from the accepted standards of care:

• • Nursing admission assessment and documentation by ED nurses — moderate to severe departure.
  • Standard of diabetic management over the course of Mr A’s admission — moderate to severe departure.
  • Appropriateness of overall management of Mr A in light of his age, frailty, cognitive impairment, and consideration of delirium — severe departure.
    
    

Opinion: Health NZ — breach

20. At the outset, I express my sincere condolences to Mr A’s family. Mrs A was closely involved in her husband’s care, and his sudden death has been traumatic for her and the family.
    
    
21. Having reviewed all the information on file, including Health NZ’s AER and the clinical advice, I find that Health NZ failed to provide Mr A with a reasonable standard of care in accordance with Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code).
    
    
22. I am critical of the care provided to Mr A in the ED. As stated by RN Picken, there is minimal documentation of the care Mr A received, and limited evidence of a nursing assessment, particularly with respect to Mr A’s diabetes. I am especially critical of the lack of BGL monitoring in the ED given that Mrs A had alerted staff that Mr A was taking insulin. I am concerned that the lack of care led to Mrs A checking Mr A’s BGL and administering the insulin herself.
    
    
23. Once Mr A had been transferred to CCU3, regular BGLs were recorded. The afternoon nurse recognised when Mr A became hypoglycaemic, and she sourced appropriate food to correct this. However, I am critical that the nurse did not check whether Mr A had eaten the food or recheck his BGL afterwards. I am concerned that she did not check Mr A’s whereabouts, and she delayed her escalation to the nurse coordinator. In the context of Mr A’s underlying cognitive impairment and hypoglycaemia, this was crucial. The delay in searching for Mr A meant that his BGL dropped further. While there was a lack of critical thinking by the afternoon nurse, I also note that there were failures by Health NZ in ensuring that there was adequate food available within CCU3, as this delayed the afternoon nurse in correcting Mr A’s hypoglycaemia and likely contributed to Mr A leaving the unit in search of food. Moreover, I am also critical of the inadequate systems in place to alert staff when patients leave the unit, and that Mr A was able to walk past seven staff while outside the unit, with none of them stopping to assist him.
    
    
24. Overall, I consider that the nursing care provided to Mr A was very poor regarding the management of his diabetes.
    
    

Changes made since events

25. Health NZ has made the following changes since the events:

1. 1. All doors in and out of the CCU are now more secure, with swipe-card access to get in, and a door-release button on a side wall to get out of the unit. The door can be locked from a central point if required. There is also signage at exits to remind patients and family to let a nurse know when they are leaving and where they are going.
      
      
   2. The fire door in CCU3 is now alarmed to alert staff if the door has been opened. It is not locked, as it remains a fire exit.
      
      
   3. Each day, the fridges in all the CCUs are checked to ensure that there is a sufficient stock of snacks for patients with diabetes.
      
      
   4. An educational session regarding the management of diabetes was undertaken across the Cardiology service. Part of this education was to ensure that there is a clear understanding of the guidelines and policies.
      
      
   5. Staff now ensure that patients with identified low BGL receive their food and/or treatment in a timely manner and, where this does not occur, an escalation process is initiated.
      
      
   6. Management of patients with dementia has also been addressed by implementing additional strategies to maximise environmental calming and individual routines into care. This aids in the recognition of specific triggers that can cause agitation for patients with dementia and assists staff in developing personalised strategies to manage these triggers.
      
      
   7. Staff now ensure that patients at risk are placed more centrally in the CCU, closer to the nursing station.
      
      
   8. Health NZ is in the process of identifying a patient monitoring system that will work within the acute environment, which can facilitate independence while also providing traceability of the patient.
      
      
   9. The emergency nursing department received education in March 2025 regarding the expected standards of recording assessments and shift summary reports. Subsequently, there has been weekly auditing of the documentation.
      
      
   10. A new electronic documentation suite, called Centrix, will replace the clinical progress notes, vital signs, and forms at Health NZ Waikato in 2027.
       
       

Recommendations

26. I recommend that Health NZ Waikato complete the following actions:

1. 1. Provide a formal written apology to Mrs A and her family for the breach of the Code identified in this report. The apology is to be sent to HDC within three weeks of the date of this report, for forwarding to Mrs A.
      
      
   2. Provide education sessions on the expectations for nursing documentation within the ED, including the use of the ABCDE[7] tool and recording of clinical history, allergies, and medications every time a nurse receives a new patient. Evidence of completion of this education by way of staff attendance records is to be sent to HDC within three months of the date of this report.
      
      
   3. Provide HDC with evidence of the last three months of the weekly documentation audits undertaken in the ED, including analysis of the findings of the audit and any corrective actions taken, within 12 months of the date of this report.
      
      
   4. Consider implementing an electronic documentation system in the ED. An update on this consideration is to be sent to HDC within 12 months of the date of this report.
      
      
   5. Undertake a random audit of 15 patients with diabetes who presented to CCU3 over the last 12 months to check whether the diabetes management was adequate. The findings of the audit, including any corrective actions, are to be sent to HDC within 12 months of the date of this report.
      
      

Follow-up actions

27. A copy of this report with details identifying the parties removed, except Health NZ, Waikato Hospital, and the clinical advisor, will be sent to Diabetes NZ and the Health Quality & Safety Commission Te Tāhū Hauora and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

Carolyn Cooper

Aged Care Commissioner