Hospitals blunders blamed for deaths

Photo / Paul Estcourt

Two elderly patients who experts believe could have survived died after lapses in their care at public hospitals.

The doctors and provincial hospitals concerned have been faulted by outgoing Health and Disability Commissioner Ron Paterson in reports made public yesterday.

The reports highlight the great risks for patients from poor supervision of health workers and weak communication among them.

The first case involved an independent and active man aged 85.

"Mr B" died in Wanganui Hospital in 2006 after complications from surgery to remove his gallbladder.

The other was a 75-year-old woman who died in 2008, probably from a heart attack, after a junior locum doctor at Whangarei Hospital thought she was having a panic attack and discharged her from the emergency department.

When Mr B had surgery, the surgeon, Dr D in the report, installed a tube, intended to remain for a month, to drain bile into an external bag.

The night before the patient was discharged, a nurse noticed the tube had been dislodged and asked another surgeon, Dr C, to check it.

Dr C tried once, unsuccessfully, to ring Dr D at home and advised the nurse to tell the patient's surgical team. The nurse had noted the wound dressing was "very oozing and smelly" and the tube was removed.

Mr B deteriorated and was re-admitted five days later.

Dr D became aware of his readmission two days after that, reviewed him that morning and confirmed that the wound was infected. He did not notice that the T-tube was absent. Despite further surgery, Mr B died 12 days later.

Mr Paterson said Dr D failed to manage his patient's post-operative care properly.

"It was inexcusable that, because of inadequate medical review, Mr B's significant complications went unrecognised by the responsible surgical team for nine days."

Both surgeons and the district health board have apologised to Mr B's family.

The Whanganui District Health Board yesterday said it accepted the finding against it, but objected to Dr C's being criticised for not personally telling Dr D about the tube.

It said that Dr C's "minor role" did not warrant an adverse finding.

In the Whangarei case, the 75-year-old woman went to an accident and medical centre because she was short of breath and had chest pain.

She was taken to the hospital's emergency department by ambulance and seen by a locum medical registrar.

The doctor diagnosed a panic attack and sent her home less than two hours after her arrival. She stopped breathing soon after. A family member and ambulance officers tried to revive her but she died. Heart disease was thought the most likely cause.

When he discharged her, the locum had only interim blood test results. Unknown to him at the time, the full results had just become available.

They showed an abnormal level of the protein troponin, indicating a heart attack might have occurred.

Mr Paterson said the locum's diagnosis was inappropriate in light of the patient's history and symptoms.

But he also criticised the Northland DHB for providing inadequate support and supervision, and for arduous working conditions that increased the risk of tiredness and errors.

The locum was working 15-hour shifts and had not been told to keep senior colleagues fully informed about patients.

"There remains a culture in New Zealand of junior doctors not wanting to 'bother the boss'," a medical adviser told the commissioner.

Mr Paterson recommended that new locums and registrars in the hospital's emergency department discuss all acute cases with an experienced colleague or supervisor before discharging them.

Northland DHB and the locum have apologised to the patient's family.

Chief medical adviser Dr Gloria Johnson yesterday listed changes the board had made because of the case, including greater supervision of locums and junior registrars, better rosters for registrars, and employing more of them, reducing the need for locums.

Taking gifts 'exploitation'

A social worker inappropriately accepted gifts worth around $55,000 from a mental health client, an investigation has found.

Deputy Health and Disability Commissioner Rae Lamb, in a report made public yesterday, named the social worker as Parehe Nikau.

She said Ms Nikau, also called Polly Haenga, worked for a primary health organisation, but did not name it.

The independent prosecutor in the commissioner's office is considering whether to take the case to the Human Rights Review Tribunal, which can award compensation.

The client, in her 60s with a long history of depression and bipolar disorder, told Ms Lamb she gave money, clothes, jewellery and other gifts to Ms Nikau, her community health co-ordinator, during the last three months of 2008.

She said Ms Nikau asked for them.

Ms Lamb said Ms Nikau accepted that the value of the money and goods was around $55,000, but denied asking for any of it.

Ms Nikau had recalled receiving $5000, which she had agreed to put in an investment account for the woman.

She had repaid that sum after being asked to do so.

The gifts included about 20 pairs of shoes, 40 pairs of underwear, 20 items of clothing and three necklaces, and winnings from gambling.

Ms Lamb said the social worker's conduct was an abuse of the trust placed in her and amounted to financial exploitation.