Hospital criticised over teenager's death

By MARTIN JOHNSTON health reporter

A coroner has criticised North Shore Hospital over its "poorly organised and inadequate" care of a teenager who died of meningococcal disease.

Dr Murray Jamieson has also criticised the Waitemata District Health Board for its initial denials of errors in treating Glen Fisher.

Mr Fisher, a 17-year-old fitness centre attendant, died in Auckland Hospital of blood poisoning caused by meningococcal disease in August 1998.

North Shore Hospital staff at first wrongly diagnosed his condition as an influenza-like illness when he arrived at the emergency department at 10.15am on August 4.

His symptoms included lethargy, sweating, fever, nausea, diarrhoea and sore muscles, joints and throat.

He had seen a GP the previous day, who had diagnosed flu, and felt unwell overnight.

The right diagnosis was made at around 3.45pm in North Shore Hospital's acute assessment ward (AAW), when Mr Fisher was probably "beyond rescue".

Antibiotics were given to him even later. He was transferred to Auckland Hospital but died.

"The care Glen received in the AAW was poorly organised and inadequate," Dr Jamieson said in findings made public yesterday after a six-day inquest held in February and May.

"Few of the staff working there on that afternoon can escape the criticism that Glen Fisher was not provided with nursing and medical care of an acceptable standard."

Staff had failed to perform simple tasks which would have shown them Mr Fisher was very sick when he arrived in the ward about 2pm and that he was deteriorating.

" ... nurses did not succeed in their first duty of taking pains over the welfare of their patient, doctors in the ward declined requests made by nurses which required application of the basic medical practice of seeing the patient and then, once the diagnosis was made, the giving of antibiotic treatment was delayed."

The nurse at first responsible for Mr Fisher in the assessment ward did not carry out any observations of his vital signs when he arrived, a serious omission for which she had apologised to the Fisher family.

One of the staff who cared for Mr Fisher in the ward, Dr Heather Gardner, failed to respond with sufficient urgency.

The doctor who finally made the right diagnosis, Dr Weldon Chiu, was repeatedly interrupted by phone calls.

But Dr Jamieson noted that meningococcal disease is a "treacherous" illness that is difficult to diagnose and can kill quickly, and that the health board had apologised to the Fisher family.

Mr Fisher's mother, Sally Fisher, who had to arrange for his autopsy herself, yesterday expressed disappointment at Dr Jamieson's findings.

Despite his criticisms of individuals, his focus was on systems, said Mrs Fisher, a nurse.

"I was trying to get something done with doctors and nurses and sorting out problems at North Shore Hospital."

She felt she had failed and she did not know what more she could do.

The chief executive of the health board, Dr Dwayne Crombie, said it accepted all the coroner's recommendations and was implementing them.

Since Mr Fisher's death, the emergency and acute-assessment facilities had been merged and upgraded, the number of medical teams had been increased and emergency-medicine specialists had been employed.

Neil Beadle, the lawyer for Drs Gardner and Chiu, said the Health and Disability Commissioner had already found they were not at fault.

Dr Jamieson, in commenting on the hospital's initial denial of errors it later acknowledged, cited a 1999 hospital letter to the Accident Compensation Corporation which stated that "regular observations were put in place to note any deterioration" in Mr Fisher's condition.

"Regrettably," Dr Jamieson wrote, "the reaction of healthcare providers to error is too frequently characterised by delay, denial and defensiveness.

"These run counter to communication and the resolution of shock and anger and lead to suspicion and mistrust, and, in the end, to a wearying inability to reach closure in the grieving process."

His recommendations include:

* Where a health provider believes its staffing and training are insufficiently funded for a safe service, it must tell the funding authority plainly.

* North Shore should include regular reviews of meningococcal disease in its staff orientation and continuing education programmes.

* The Waitemata health board should develop an adverse-event policy. This should require early involvement of senior staff in frankly and empathetically addressing affected families' three key questions - what happened, why, and what can be learned to minimise the chances of similar events occurring.