A health authority has been found at fault for failing to ensure a woman given a sedative for pain relief had enough information about what she was taking. Photo / 123RF
A health authority has been found at fault for failing to ensure a woman given a sedative for pain relief had enough information about what she was taking. Photo / 123RF
A woman seeking help for leg pain at a crowded hospital emergency department claimed she ended up unconscious and thought she would die after she was given a sedative, without fully knowing what it was.
In November 2019 the woman was taken by ambulance to hospital where she spent an hour and 45 minutes in the corridor with a pain level she described as close to 10 out of 10 before she was placed in an "overflow bed".
Her arrival at hospital coincided with what was described as a "very busy time", and several days after she was first treated for leg pain and discharged from the emergency department.
She was given standard pain relief medication in the ambulance on her way to hospital the second time, but once there and after initial assessment following triage she was eventually given the sedative droperidol.
The woman was not assessed by a doctor at any time during her stay.
A minute after being given the sedative she began having what she described as an adverse reaction which she said began with her being unable to talk or move, leading to her eventually being unconscious.
Te Whatu Ora - Te Pae Hauora o Ruahine o Tararua MidCentral (formerly MidCentral DHB) has now been found to have breached the Code of Health and Disability Services Consumers Rights, for failing to ensure the woman had enough information to give informed consent to the off-label use of a sedative medication.
Deputy Health and Disability Commissioner Deborah James. Photo / Supplied
In a decision released today, the Deputy Health and Disability Commissioner said the woman arrived at the hospital emergency department during a very busy time.
Without being reviewed by a medical practitioner, she was given droperidol for pain relief by a registered nurse.
The woman, who was in her 30s at the time, and whose name and identifying details are suppressed, told the HDC she remembered a nurse approaching her and asking if she had heard of droperidol, and that she had not.
She recalled being told it should resolve some of the pain, and because of this she thought it was pain relief medication.
Droperidol is approved for use as a sedative in New Zealand. Its use as pain relief is considered "off-label". It is recommended that patients are monitored carefully after its administration, but no such monitoring occurred, the report said.
The woman stated that if she had been told the drug was a sedative, she would not have given consent as she is a busy mum; she knows sedatives make people sleepy and she "never would have been okay with this".
The side effects she reported began soon after the drug was given included that she was left feeling helpless as she was unable to talk or move, her tongue was folded inside her mouth which "did not work", and she felt "stuck inside" her body".
She experienced involuntary muscle spasms, could not control her thumbs and arms, her back arched involuntarily, and she became unconscious.
When she woke her watch recorded that her heart rate had dropped to 38 beats per minute. She felt scared and traumatised and thought that she would die in the hospital if she stayed.
Mrs A submitted that once she was able to move, she asked a different nurse to help her, but the nurse did not hear her, so she removed the intravenous line and "got told off".
MidCentral DHB told the woman that the "seizure" she reported having experienced was not witnessed or reported by the nursing staff and was not documented.
The woman's medical records showed that she discharged herself at 7.22pm, soon after the emergency department went into red status – which meant the service was operating in a critically degraded state.
It was recorded as being under control again by 9.30pm that same evening.
The doctor who prescribed the drug could not be identified, therefore deputy commissioner Deborah James considered the health authority to be responsible for the failure around not informing the woman.
MidCentral DHB said the signature on the front of the medication chart could not be identified, and there was no Medical Council of New Zealand registration number.
The health agency told HDC that it circulated the medication chart and no one was able to identify the signature on the chart.
All ED consultants working that day confirmed that it was not their signature.
James said the woman should have been told what was being prescribed, and its primary use as a sedative, side effects, and why it was being prescribed for her as pain relief, including that it was not approved for use as such.
"This was information that a reasonable consumer in Mrs A's circumstances would expect to receive and needed to receive to give informed consent."
James was also critical that staff failed to monitor the woman after droperidol was administered, despite a clear expectation this should have happened.
It meant the adverse reaction went unnoticed, and the DHB's questioning of whether the woman had in fact experienced an adverse reaction had caused her unnecessary distress.
"I remind MidCentral DHB of the importance of acknowledging the patient's experience, and of reflecting and taking learnings from such experiences, to identify any areas for improvement," James said.
A number of recommendations included that the DHB apologise to the woman, undertake an audit of the emergency department waiting times and provide the HDC with an audit of emergency department medication charts over the past six months.
This was to check the compliance of doctors entering Medical Council of New Zealand registration numbers on the medication chart.
MidCentral DHB said it has since devised a medication charting guideline for patients waiting to be seen in ED, and a list of medications allowed to be given to patients waiting to be seen.
This includes medications which can be given by registered medical officers and which areas of the emergency department are appropriate for the administration of specific medications.
