Healthboard makes Changes after youth's death

Ben Brown

A series of system changes at Northland's hospitals mean the "significant errors" that led to the death of Whangarei youth Ben Brown from meningococcal disease won't happen again, the Northland District Health Board says.

A coroner's report released this week into the death of Mr Brown, 18, in August 2011, found antibiotics may have masked the meningococcal disease that killed him, but there were "frailties and problems" with the Whangarei Hospital system that contributed to his death.

In his evidence to the coroner's hearing, health board CEO Nick Chamberlain acknowledged the DHB had made significant errors that contributed to Mr Brown's death - including full results of a CT scan not being read for 36 hours, poor communication and note taking.

Dr Chamberlain said the board was deeply remorseful for the shortcomings and had conducted two independent reviews, covering the actions of the Emergency Department and ICU, acting on every recommendation made.

NDHB chief medical officer Mike Roberts said all the issues identified in the external reviews had been addressed and that this had led to a real improvement in patient safety.

As a result of the internal review, the DHB changed the clinical steps it took to diagnose meningococcal disease and introduced a new type of blood test (procalcitonin) to assist clinicians in identifying such a serious disease.

"This new blood test does not guarantee meningococcal disease will be found, but it helps to identify serious infections like meningitis at an early stage when the symptoms are not yet obvious," Dr Roberts said.

"The test is not yet widely used in New Zealand but our specialists believe it is another tool we should use to minimise the risk that the disease is not identified as early as possible.

"Meningococcal disease is one of the most difficult to diagnose as patients often present with a range of symptoms, such as headache or fever that are consistent with a number of other much less serious illnesses.

"The disease can develop rapidly over a few hours and may not show up in routine blood tests."

As a result of the recommendations, the DHB has also:

Increased ICU specialist staff levels to provide for full and unhurried handovers and to allow a second specialist to be on site and immediately available to assist the duty specialist and appointed an intensivist.

Developed joint guidelines between the ED and the departments of Anaesthesia and Intensive Care.

Reviewed, and where necessary revised, the systems and standards for the interim reporting of emergency imaging findings. A formal process was introduced to ensure CT scan reports are not released until they have been finalised.

Amended meningococcal advice leaflet highlighting the specific risks of prior antibiotic treatment masking the disease.

Induction programme for ED doctors highlighting importance of listening to family concerns and the pitfalls of diagnosing meningococcal disease.

Reviewed Whangarei Hospital ED staffing to improve evening and night cover.

ED has hired four extra doctors to increase evening and night cover.