A woman in her 70s died of sepsis after a perforation occurred during surgery to remove cancer. Photo / 123rf.com
When a woman underwent an outpatient procedure to remove cancer from her small intestine, a suspected perforation occurred and she was admitted to hospital as a precautionary measure.
But during her admission, the woman’s condition deteriorated and she was diagnosed with pancreatitis.
Three weeks after the initial procedure, the woman, in her 70s, had emergency surgery to treat the perforation but died days later of sepsis.
Now, Deputy Health and Disability Commissioner Carolyn Cooper has released a report into the woman’s post-operative care which found several deficiencies.
Cooper said the inadequate care provided was not the result of isolated incidents involving one or two staff.
“They were widespread, involving many staff members, which is a reflection of Health NZ’s poor systems at the time, which I consider constitutes a departure from the expected standard of care for [the woman].”
According to the report released today, the woman’s case was brought to the attention of the Health and Disability Commissioner (HDC) in a complaint by her grandson about her care.
The report, which does not name the woman or the health board involved, said the procedure used to remove the woman’s cancer was technically complex and risked perforation, bleeding, and pancreatitis.
While the cancer was successfully removed, it was recorded there was a possible micro-perforation at the opening of the woman’s pancreatic duct caused by a thin wire used to control the movement of equipment during surgery.
The gastroenterologist who performed the surgery inserted a metal stent, a tube to open the passageway, as a standard treatment for possible perforations.
The patient was admitted to hospital and given antibiotics.
But during her stay she developed pancreatitis and her condition fluctuated between periods of improvement and deterioration.
She was managed non-surgically under the care of four specialists.
The report stated she was cared for in the gastroenterology ward where she suffered vomiting, nausea, bloating and abdominal pain.
She was given intravenous fluids, anti-nausea medication and pain relief, and had X-rays that were considered normal and did not show evidence of perforation.
However, blood tests later showed the woman’s inflammatory markers were elevated, and she had a fever.
After further investigation, a CT scan reported a swollen pancreas with mild to moderate amounts of free fluid.
The scan was consistent with moderately severe pancreatitis but also did not show a perforation.
The woman’s care was transferred to general surgery, where her symptoms continued to fluctuate and her temperature spiked at least once a day.
She was reviewed four times and it was noted that despite her pancreatitis, she was eating and drinking and that she was “bloated but a lot better”.
A secondary diagnosis of constipation and dehydration was made, and a dietary plan was made that included laxatives.
The woman’s temperatures continued to spike but a registrar explained that post-procedure bloating was expected, and she could be discharged if her fevers settled and she was eating and drinking normally.
Her care was eventually transferred to an upper GI specialist who went on to suspect the woman likely had a contained “retroperitoneal type two perforation” and that this was complicated by pancreatitis.
The specialist ordered a further CT scan, dietitian input and antibiotics to continue.
The scan showed no abscess but indicated a progressive inflammatory change of the duodenum, the first part of the small intestine, and pancreas, with a moderate fluid collection.
In the following days, the woman’s heart rate began to trend higher than normal and her condition deteriorated significantly with her fever, bloating, and vomiting continuing.
She went on to excrete a large amount of dark, foul-smelling fluid daily from her nasal tube.
The woman continued to be monitored but was considered stable and the impression was possible infection secondary to pancreatitis or a retroperitoneal fluid collection. Further investigations were made.
Then, about two weeks into her admission, the woman’s antibiotics were stopped unexpectedly.
Health NZ told HDC a junior doctor made the decision, but given the passage of time and the lack of clear documentation, was unable to give a reason for this.
The woman continued to have a high heart rate and temperature, and at times low blood pressure. She also developed significant new symptoms including malnourishment and abdominal distension.
After multiple reviews from various medical staff, a registrar noted a retroperitoneal – the area in the back of the abdomen behind the peritoneum – collection of fluid that may have changed in size, and pancreatitis.
The record noted: “[F]indings are suspicious for a duodenal perforation” which the HDC found was the first recording that a perforation could be a potential or actual cause of the woman’s post-operative symptoms.
The registrar told the woman’s family there was a perforation in her bowel that was getting worse and she required an urgent operation.
She was taken to theatre and a post-operative note recorded the findings of a large retroperitoneal abscess with dead tissue and extensive inflammation.
After the procedure she was transferred to the intensive care unit (ICU), where she died days later.
The ICU consultant recorded her cause of death as sepsis secondary to the duodenal perforation and a referral to the Coroner noted the emergency surgery confirmed a perforation had occurred.
In contrast, the operation notes made no comment regarding a perforation, and Health NZ told the HDC that the surgeon had been unable to identify a perforation, and both Health NZ and a gastroenterologist said that most likely her death occurred due to pancreatitis.
Health NZ said no investigation into her care was completed.
After her investigation, Cooper acknowledged the complexity of the case, “as evidenced by [the woman’s] fluctuating clinical course” and the high risks associated with the initial procedure.
“I consider that several systems issues cumulatively led to [the woman] receiving a poor standard of care,” she said.
“However, I note that had an appropriate standard of care been provided, [her] outcome may not necessarily have changed.”
The woman’s grandson told the HDC that clinicians remained focused on the treatment of his grandmother’s pancreatitis rather than exploring other causes for her deterioration.
He said the possibility of the initial perforation having not healed was queried by the family, but the clinicians insisted the perforation had healed on its own.
Cooper said that whilst it was not disputed that a perforation may have occurred during the initial surgery, the possibility of a perforation as the cause of the post-operative symptoms was not documented until 21 days later.
“There is conflicting evidence as to whether, prior to that date, clinicians were considering whether the post-operative symptoms could have been caused by a perforation (as opposed to pancreatitis).”
Cooper said she didn’t need to make a finding on that matter.
“I am reassured that the clinicians involved did take action to investigate the suspected perforation, at least immediately after [the woman’s] operation.”
She said knowing whether a perforation had occurred would not have changed the day-to-day management of the woman’s symptoms.
In considering the non-surgical management of the woman’s condition and delay in operation, Cooper was satisfied the treatment options were considered carefully and found non-surgical management was not an unreasonable treatment option.
However, Cooper was critical of several other aspects of the woman’s care, leading to a breach of the Code of Health and Disability Services Consumers’ Rights.
She found inadequacies in the communication provided to the woman and her family, a failure to continue antibiotics when this was clinically indicated, an absence of a shared understanding between providers, leading to a fragmented approach to care, and a failure to complete documentation adequately.
Cooper made several recommendations including that Health NZ provide a written apology to the woman’s family.
She also made recommendations around clinical documentation and referrals of patients with complications similar to the woman’s.
Health NZ told the HDC it had made several changes since the woman’s death, including an education session for the Department of General Surgery on the management of perforations after the procedure done in this case.
They allege the Crown ignored Treaty obligations by not engaging with them.