Woman died after failure to spot meningococcal disease

Nileema Sharan might have lived had hospital and emergency staff recognised the seriousness of her illness and treated her at any time up until the morning of her death, the Wellington coroner has found.

Miss Sharan, 25, died of meningococcal septicaemia on June 26 last year - the day after travelling by ambulance to Wellington Hospital's emergency department after apparently hurting her neck at work.

She waited almost three hours to be seen but eventually gave up and saw a doctor at an urgent medical centre.

He diagnosed neck strain, prescribed pain relief and sent her home.

At about 1.30am her flatmate found her lying on the floor, delirious. He gave her water and returned her to bed, where she was found dead the next day.

Coroner Garry Evans criticised the emergency department's priorities and delays, the lack of communication between the department and the medical centre general practitioner, and the GP's failure to take a complete history - he was unaware Ms Sharan had spent three hours at Wellington Hospital.

"While it cannot be said on the evidence that Ms Sharan's death was preventable, it can be said that she missed the opportunity, which she should have had, of complete examination and assessment at the hands of departmental medical staff," Mr Evans said.

He criticised the hospital triage nurse's decision to reduce Ms Sharan's priority level from a category three - to be seen within 30 minutes - to a level four, with a 60-minute wait.

The emergency department should have taken Ms Sharan's vital signs, including her temperature - which could have suggested a more serious illness - during her wait.

Staff numbers were inadequate to cope with the number of patients that day, and the triage nurse was so overloaded she could not do her job properly, Mr Evans said.

The evidence showed that, had anyone realised the seriousness of Ms Sharan's condition up until the morning she died, treatment might still have saved her.

But even if she had seen a doctor who found her symptoms showed something more serious than a simple neck strain, there was no guarantee meningococcal disease would have been diagnosed, he said.

Capital and Coast District Health Board chief executive Margot Mains accepted there were several areas where the case "could have been handled more effectively".

But emergency department acting clinical leader Marjory Vanderpyl said if Ms Sharan came into the department today with the same symptoms, she was "not convinced" a doctor would be able to diagnose meningococcal septicaemia.

Ms Mains said a number of improvements had been introduced across the whole hospital.

The number of senior medical officers had increased from 1.4 in 2000 to five at present. That would increase to eight as staff became available.

Five more nurses had been funded, but there were still vacancies.

An overload policy had been introduced, with different alert levels. As the alert level was increased, extra staff would be brought in from elsewhere.

Waiting times had also "dramatically improved", Dr Vanderpyl said.

Ms Mains said the board was improving bed management to prevent patient logjams and setting up transit lounges for discharged patients waiting for transport. National Party associate health spokesman Paul Hutchison said the coroner's report was an indictment of basic medical processes at Wellington Hospital.

- NZPA