Miscommunication, confusion and delays - including a locked hospital door - surrounding ambulance and hospital care of a critically ill woman did not contribute to her death, a coroner has found.
Coroner Brandt Shortland has highlighted a series of miscommunication and delays between St John Ambulance and Northland District Health board staff following his inquest into the death of Jacquelin Pukeroa, who died on August 22, 2007, as the result of a haemorrhage and rupture within her pancreatic pseudocyst.
She died at Bay of Islands Hospital after being transported from her home by a St John ambulance. Mrs Pukeroa's family had called an ambulance at 6pm but she did not arrive at the hospital until 7.41pm, when it was found the hospital door was locked, delaying her entry.
The coroner found that the St John ambulance officer who attended her home recorded Mrs Pukeroa as a triage "status three" patient. However, medical evidence presented to the coroner from Middlemore Hospital emergency medicine specialist Louise Finnel said Mrs Pukeroa's health should have initially been classed as "status two" - in a serious condition with potential threat to her life.
When Mrs Pukeroa's condition worsened on the way to the hospital she had become "status one" - in critical condition, with an immediate threat to her life. Dr Finnel said a status two rating would have activated the hospital's emergency response procedure and the ambulance would have been met by a nurse and/or doctor at the hospital.
"This catastrophic event probably occurred around 5.30pm and when the ambulance officer arrived, her vital signs (recordings) were already abnormal. With the benefit of retrospective analysis, Mrs Pukeroa was in barely compensated haemorrhagic shock at 6.30pm," the doctor said. Even if an ambulance double crew had decided to "scoop and run" from the scene at 6.30pm (when the ambulance arrived at the house) and driven at high speed to Whangarei - some 75 minutes away - Mrs Pukeroa would have been unlikely to survive the anaesthetic, let alone any surgical procedure, Dr Finnel said.
Mr Shortland said Mrs Pukeroa's chances of survival were considered "extremely remote". Even if she had been living in a large city with access to tertiary surgical services within a five-minute period, she would probably not have survived.
Dr Finnel said the two sources of delay to hospital treatment, "namely; delay in transport, and delay in admission, did not ultimately contribute to her demise". Mixups not
She identified system errors - incorrect initial ambulance triage of a patient with very abnormal vital signs and breakdown in communication between the ambulance staff and those receiving the information at the hospital.
Mr Shortland said: "Despite the contributing facts leading to Mrs Pukeroa's death, it is clear her condition was far more serious at the time of her demise and the only treatment that may have given her a chance was never possible given the geographical distances and the availability of services required."