Director of Proceedings v Te Whatu Ora|Health New Zealand  NZHRRT 32 (11 October 2023)
The Director of Proceedings filed proceedings by consent against Southern District Health Board (now Te Whatu Ora Southern) in the Human Rights Review Tribunal (‘the Tribunal’) regarding the care provided to Mrs A (deceased) by numerous staff across Dunedin Hospital’s Emergency Department (‘ED’) and respiratory team.
Mrs A’s general practitioner referred her to the ED with a suspected pulmonary embolism (‘PE’). A CT scan confirmed a massive PE with significant effect on the cardiovascular system. The admitting registrar for the respiratory team assessed the PE as an intermediate to high risk of mortality and discussed Mrs A with the respiratory consultant on call. The respiratory doctors felt that the risk of thrombolysis (medication used to dissolve blood clots) outweighed any benefit. The plan was to admit Mrs A for observation, administer a further dose of blood-thinning medication, and consider urgent thrombolysis if her blood pressure dropped to less than 90mmHg for more than 15 minutes or she went into shock. At the time there were not enough inpatient beds for transfer of patients after treatment in the ED. Accordingly, despite being handed over to the respiratory team, Mrs A remained in the ED while waiting for a bed in the respiratory unit. Staff monitored Mrs A’s vital signs using an Early Warning Score (‘EWS’). Under the EWS, abnormal vital signs trigger an escalating clinical response from senior staff. Over a period of several hours, junior staff did not recognise Mrs A’s deteriorating clinical picture and escalate her care to a senior medical officer (‘SMO’) as per the EWS policy, and did not treat her with anything other than fluids. Sadly, Mrs A died.
Independent advice provided to the Health and Disability Commissioner confirmed that junior medical staff did not fully appreciate the severity of Mrs A’s illness. Mrs A was critically ill with PE and had many signs suggesting that she was in the high-risk category, not intermediate to high risk. This influenced the initial decision to withhold thrombolytic treatment, and likely influenced decisions throughout the night to withhold thrombolytic treatment. There were several missed opportunities to administer thrombolytics to Mrs A, which may have given her a chance of survival. The independent advisors considered that junior medical staff seemed focussed on Mrs A’s blood pressure and not her overall deteriorating clinical picture. The first line of treatment recommended for PE is aggressive anticoagulation. The administration of three litres of IV fluid as a temporising measure to correct Mrs A’s hypotension, and the withholding of thrombolytic treatment between 7.30pm and 10.35pm when Mrs A was clearly in shock, was a severe departure from the standard of care. Likewise, the failure of the medical staff involved in Mrs A’s care to recognise a deteriorating patient and escalate care to the on-call SMO was a serious departure from accepted practice. The advisors also criticised the poor standard of clinical documentation, in particular the lack of documentation of apparent medical reviews undertaken.
Te Whatu Ora acknowledged that Southern DHB staff missed multiple opportunities to exercise sound clinical judgement and assess Mrs A’s deteriorating condition critically, to follow the DHB’s EWS policy and escalate her care to the responsible respiratory SMO, to initiate thrombolysis on several occasions when it was clinically indicated, and to communicate effectively with one another. Te Whatu Ora acknowledged that this was a service delivery failure for which, ultimately, it is responsible at an organisational level. Te Whatu Ora accepted that its failures in care breached the Code of Health and Disability Services Consumers’ Rights (‘the Code’), and the matter proceeded by way of an agreed summary of facts. The Tribunal was satisfied that Te Whatu Ora failed in the care it provided to Mrs A and issued a declaration that it breached Right 4(1) of the Code.
The Tribunal’s full decision can be found at: http://www.nzlii.org/cgi-bin/download.cgi/cgi-bin/download.cgi/download/nz/cases/NZHRRT/2023/32.pdf