Middlemore Hospital in Auckland has been criticised over a vague policy, missed opportunities and "unacceptable" delay in treating a man who died from the overwhelming effects of infection.
The man, aged in his 60s, went to the emergency department in 2011 suffering severe back pain several weeks after having back and shoulder surgery, according to a report made public today by Health and Disability Commissioner Anthony Hill.
The pain was assessed as muscle and skeletal pain and he was discharged. He returned four days later complaining of pain and dizziness. At 11am a doctor queried if the man had sepsis, which is a potentially life-threatening inflammatory response to infection.
The doctor planned to give antibiotics but the orthopaedics team asked to review him first.
In the afternoon, staff from three departments reviewed him. One found his body wasn't getting enough oxygen and his kidneys were failing. A spinal MRI scan found a large, inflamed mass and an infection of the space between vertebra discs. Intravenous antibiotics were not started until 7.15pm.
At 11pm he was transferred to the orthopaedic ward and soon after to the high dependency unit because of respiratory distress. At 4.30am he was taken to the intensive care unit. He developed multiple-organ failure and died that evening.
Mr Hill says the man should have been given antibiotics soon after his admission.
"There was a lack of clear understanding in the ED regarding when it is appropriate to withhold antibiotics and clinicians were reliant on an unwritten policy that did not provide guidance regarding unstable patients."
"There were missed opportunities for clinicians to recognise that because the man was unstable, antibiotics should not have been withheld."
The delay in ICU transfer was unacceptable.
"Although he was reviewed by multiple clinicians during his time in ED, no one individual identified that the seriousness of [the man's] condition required him to be admitted to ICU, and advocated for him for this to occur. No single person had the full picture of [his] condition."
Mr Hill said Middlemore Hospital's operator, the Counties Manukau District Health Board, had breached the code of patients' rights.
"CMDHB's failure to provide clear direction and guidance to its staff regarding withholding antibiotics, together with the failure of multiple clinicians to exercise critical thinking, led to [the patient] not receiving antibiotics when indicated, and not being admitted to ICU from EC in a timely manner."
Mr Hill says the DHB apologised to the man's family and has made a number of changes to prevent a similar event occurring.
The DHB says it "unequivocally accepts" the commissioner's findings and that it has made improvements since the patient's death.
The man had "suffered a delay before he was started on antibiotics. While this delay was for clinical reasons, the protocol now states that all similar patients at risk or showing signs of sepsis must be started on antibiotics without delay, aiming for this to be within an hour of presentation.
"The severity of his illness should have been recognised at presentation and aggressive treatment started with antibiotics ...
"We fully acknowledge our shortcomings in [his] care and the documentation supporting his treatment. We are confident that, as a result of the changes we have made since 2011, patients presenting today with symptoms similar to [his] will receive different case management."