Hospital treatment deficient: coroner

Wairau Hospital did not properly manage an elderly woman's care but it was hard to say how much this contributed to her death, Blenheim's coroner has ruled.

Coroner Peter Radich said 70-year-old Rosemary Bull's death in December 1997 at Wellington Hospital was due to respiratory failure following pneumonia and peritonitis.

She had been transferred from Wairau on November 28 after her condition deteriorated.

Mr Radich said the lack of an autopsy made it impossible to be more accurate about cause of death or how the treatment at Wairau contributed.

Mrs Bull was admitted to Wairau on November 15 after seriously damaging her knees in a fall.

She had surgery and was admitted to a surgical ward.

Mrs Bull was suffering from renal (kidney) failure when admitted, which she treated through self-dialysis.

Mr Radich said the hospital failed to recognise that treatment for her knee injuries could affect her underlying condition.

"In fact, Mrs Bull's overall condition was not properly managed at Wairau Hospital in that there was no adequate coordinated treatment of her surgical and medical conditions."

Mrs Bull was prescribed the painkiller pethidine while in hospital.

Pethidine is not recommended for renal patients but drug guides commonly used at hospitals did not record this, the coroner said.

No fair criticism could be levelled at hospital clinicians but he noted that Mrs Bull suffered from pethidine toxicity while at Wairau.

Mr Radich said there was a communication breakdown between surgeon Rod Maxwell, hospital physician John Hedley, nursing staff and house surgeons.

Dr Maxwell told the hearing he had asked for and understood that Mrs Bull was receiving medical care for her renal condition. But Mr Radich said notes were sketchy.

"It is quite unsatisfactory that something as potentially significant as a cloudy bag [a sign of possible infection] could be, was not recorded in the clinical notes."

The case has also been reviewed by the Health and Disability Commissioner, who ruled that both Dr Maxwell and Nelson-Marlborough Health Services, which runs Wairau Hospital, had breached parts of the Code of Health and Disability Services Consumers' Rights.

Mr Radich said he believed recommendations from that report had been acted upon and did not need to be addressed by him.

- NZPA