The treatment is usually given in an intensive care unit, but Dr B decided to do it in the ED. She also prescribed the drug tenecteplase, rather than the expected drug alteplase. They are in the same class of drugs but in New Zealand tenecteplase is used for heart attacks rather than ischaemic strokes.
"Dr B prescribed Mr A tenecteplase because she understood from nursing staff that there was no alteplase available at the hospital," Mr Hill says.
"In addition, she was aware of studies that support the use of tenecteplase in stroke. However, she followed the New Zealand Formulary ... guidelines for the use of tenecteplase in myocardial infarction [heart attack].
"In doing so, she prescribed Mr A at least twice the dose of tenecteplase recommended for treatment of ischaemic stroke. In addition, she prescribed tenecteplase to be administered as a 10 per cent bolus with the remainder to be administered as an infusion over one hour (the correct mode of administration for alteplase), whereas tenecteplase should be given as a single bolus (i.e., all at once)." While the drug was being given to the man, the house officer was told alteplase was available after all, at the hospital's ICU. She phoned the specialist who said to continue the infusion of tenecteplase.
The man at first showed signs of improvement after the infusion, but a CT scan the next morning revealed a brain bleed.
"Mr A deteriorated over the following three days and, sadly, he died from intracerebral haemorrhage," Mr Hill says.
The house officer made "significant errors or judgement", which amounted to failing to provide health care with reasonable care and skill. The errors included failing to transfer the patient to the ICU, the dosage and mode of administration of tenecteplase and failing to consult the specialist about the use of that drug.
The DHB's stroke clot-busting therapy guidelines were inadequate, the house officer had not received adequate orientation to the guidelines, and there was "evident confusion" amongst nurses about the correct process for administering the therapy.
"NMDHB had a responsibility to ensure that its staff had the right tools, including adequate policies and training, to provide this service safely." Mr Hill asked both doctors and the DHB to apologise to the patient's family. He also recommended the DHB report back to him on an audit of compliance with its updated stroke guidelines, a review of junior and new staff orientation, and changes to its error-reporting system.
He also asked all DHBs to check their stroke clot-busting therapy guidelines are clear and consistent.
Nelson Marlborough DHB chief medical officer Dr Nick Baker says: "We are sorry about the circumstances that led to this person's death and acknowledge that it has been awful for the family.
"Stroke is a very dangerous, complicated condition and the timing of treatment is critical.
At the time, this particular stroke treatment was relatively new and only applied to a small percentage of stroke patients.
"We have learnt considerably from the events around this death. We have since employed more senior doctors to support junior doctors' work, and audits of two further applications of this particular treatment have resulted in 100 per cent compliance. We are also piloting a 'tele-stroke' system where a stroke expert is available on the phone to support our clinicians."
Stroke failings identified
• Patient suffering stroke from a clot in an artery was in error given a double dose of clot-busting therapy
• He suffered a brain bleed and died
• Junior doctor and district health board faulted by health
• DHB's stroke guidelines were judged inadequate
• Doctor hadn't received proper orientation
• Nurses were confused about correct delivery of stroke therapy
