Death of ‘critically unwell’ Taranaki patient after sepsis missed by three doctors

The Health and Disability Commissioner found care of the patient fell significantly below accepted standards at Taranaki Base Hospital. Photo / Tara Shaskey

A woman sent to a hospital emergency department by her GP died from sepsis after the “life-threatening condition” went unnoticed by three doctors, despite tests strongly indicating the deadly infection.

Now, the Health and Disability Commissioner [HDC] has found Te Whatu Ora Taranaki breached the Code of Health and Disability Services Consumers’ Rights for failures in the care of the woman at Taranaki Base Hospital.

Te Whatu Ora Taranaki has now been referred to the Director of Proceedings, indicating the seriousness of the failings.

The woman, identified as Ms A and aged in her 40s, had colorectal cancer that had spread and had been undergoing radiotherapy overseas for seven months to extend her life.

She returned to New Zealand but continued to feel unwell post the procedure, according to a decision released today by Deputy Health and Disability Commissioner Dr Vanessa Caldwell.

Ms A’s GP referred her to the hospital the following day as she was experiencing dehydration nausea, vomiting, diarrhoea, apparent weakness, and a high heart rate of 100.

At 1.30pm Ms A was admitted to the ED and triaged as category 3; “potentially life-threatening or important time-critical treatment or severe pain”.

At 5pm Ms A was seen by a medical house officer, who did some blood tests and gave her pain relief medication.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell expressed her sincere sympathy to the woman's family for their loss. Photo / Supplied

Her blood tests revealed she was critically ill, and the doctor discussed this with two other doctors, but no clear diagnosis was reached.

They decided to transfer Ms A to a general medical ward once a bed became available.

At 10pm Ms A was transferred and had a CT scan that found severe ascites, where fluid collects in spaces within the abdomen but was negative for a liver abscess or peritonitis, or inflammation of the lining of the stomach.

Between 12am and 2.15am Ms A had two short episodes of unconsciousness including bowel and bladder incontinence during the first episode.

A doctor rang the ward’s emergency bell during the second episode of unconsciousness at 1.15am, when Ms A recovered consciousness after 30 seconds.

Ms A’s blood pressure was unreadable and she was recorded as looking “very dry” and having ongoing pain.

At around 2am the doctors decided Ms A should be transferred to the high-dependency unit [HDU] as she was “exceptionally unwell”.

It wasn’t until 4.30am that Ms A was given antibiotics to treat presumed abdominal sepsis. She was later given vasopressor medication to maintain her heart rate and blood pressure.

Ms A’s family arrived at the hospital at around 4.30am. An hour later her blood pressure started to drop and she went into cardiac arrest.

She was resuscitated, requiring ventilation but did not respond to supportive treatment.

Following a discussion with her family, Ms A was extubated at around 8am and she passed away 20 minutes later.

Her death 19 hours after she presented to the ED was due to sepsis, the body’s extreme response to infection.

Caldwell said in her decision that due to “significant” treatment delays, Ms A did not see a doctor, receive pain relief and fluid therapy, or have blood taken until several hours after her arrival in the ED.

Her blood results were “highly abnormal”, strongly suggesting sepsis and that she was about to become critically unwell, all of which was not recognised in the ED.

The report stated that the three doctors looking after Ms A did not “share a common mental model” about diagnosis or treatment and didn’t recognise Ms A’s “immediately life-threatening condition” or consider sepsis.

Ms A’s initial admission to a medical ward rather than the HDU was “clinically inappropriate” and she was not given pain relief before her transfer despite having a pain score of eight out of 10.

The report also found that earlier antibiotics and ICU therapies may have prolonged Ms A’s life.

Caldwell found that systemic and organisational issues led to a delay in the timely detection and treatment of the woman’s sepsis.

“Despite the woman’s blood results and clinical features pointing to sepsis and the need to escalate her care, there were delays by a number of staff in recognising and appropriately responding to the situation.”

She acknowledged that Te Whatu Ora had made a number of changes since the event, including improving its staff training and education in relation to sepsis and the use of early warning scores.

It had also introduced a 24/7 Patients at Risk nursing service and was launching a Speaking Up for Patient Safety campaign for staff.

Caldwell found the care fell significantly below accepted standards and considered it to be in the public interest to hold Te Whatu Ora accountable for that service delivery failure.

She referred the matter to the Director of Proceedings who will decide if Te Whatu Ora Taranaki should face further investigation. She also expressed her sincere sympathy to the family for their loss.

Emily Moorhouse is a Christchurch-based Open Justice journalist at NZME. She joined NZME in 2022. Before that, she was at the Christchurch Star.