Patient watchdog to examine death at Auckland Hospital of Pacific Island man Joseph Joe

Joseph Joe died at Auckland Hospital after the main artery taking blood from his heart ruptured following an emergency procedure. Photo / Sylvie Whinray

A Coroner has taken the serious step of referring the death of a patient following emergency surgery for a tear in his aorta, to a patient watchdog for further investigation.

Joseph Junior Joe died at Auckland Hospital in April 2018, a week after a stent graft was inserted into his aortic arch.

Coroner Tania Tetitaha was concerned at the medical care Joe received hours prior to his death after two doctors decided not to investigate when Joe complained of severe chest pain.

In a decision made on the papers and released today, Coroner Tetitaha noted Joe was a Pacific Island man with a history of aortic complications.

The 49-year-old father of six had undergone two previous surgeries in 2011 for a tear in the lining of his aorta - the main artery that carries blood away from the heart - and 2015 for inflammation of the lining, valve and muscle of the heart and blood clots.

It was against this background that Joe was transferred from Middlemore Hospital to Auckland Hospital on March 28, 2018 with a tear in his aorta with impending rupture.

He underwent the emergency procedure which involved the placement of a covered stent graft to open up the blood vessels in the heart narrowed by cholesterol or plaque build-up.

On April 4 Joe complained of squeezing chest pain he rated at nine out of 10 and palpitations. He was hot and sweaty, and his blood pressure was rising.

He was given pain relief but the pain had returned three hours later shortly before 4pm that day.

Despite this a house doctor and a cardiothoracic surgeon registrar discussed Joe’s case and “it appears there was a decision made to take no further investigation”.

The next morning Joe managed to go to the bathroom at 5.10am and was given more pain relief, but by 6.28am he was unresponsive and could not be resuscitated.

A post-mortem by forensic pathologist Dr Simon Stables showed Joe’s aorta ruptured and he died from the resulting haemorrhage of blood pooling in his chest.

A medical report from the hospital given to the coroner noted the rupture “would have been due to the underlying disease in his aorta (note that he had had surgery on the proximal part of his aorta twice before).”

Expert evidence provided by cardiothoracic surgeon Adam El Gamel, said there was “a small but significant risk of aneurysm rupture with endovascular stent grafting that are slightly higher than that of open chest aortic aneurysm repair”.

However, El Gamel said he was unsure whether surgical intervention at the time Joe complained of the chest pain would have saved his life.

Stables told the coroner one end of the endovascular stent had been incorrectly positioned in the recent dissection.

“This placement which would have resulted in continued increased pressure within this new weakened vascular channel, thus increasing the risk of rupture.”

Coroner Tania Tetitaha has referred the care of a man who died at Auckland Hospital in 2018 to the Health and Disability Commissioner. Photo / Tania Whyte

The coroner directed her comments at the former Auckland District Health Board, now called Te Whatu Ora Te Toka Tumai Auckland, when she pointed out that Joe was a Pacific Island man and that Pacific Island peoples experience poorer health outcomes than other New Zealanders across a number of health and disability indicators.

“In short Pacific people die younger and have higher rates of chronic diseases, which are recognised as leading causes of premature mortality and disability.”

She said cardiovascular disease was the principal cause of death and cardiovascular mortality rates were consistently and significantly higher than for the general population.

Two out of five Pacific deaths are from heart disease and aged between 35 to 65 years old. One in three Pacific men who died in 2016, died from cardiovascular disease.

It was the leading cause of death for Pacific people, Tetitaha said.

She added that aortic dissection, or a tear such as Joe’s, was a serious cardiovascular condition where patients did not survive longer than a week without surgery after symptoms appeared.

The most common symptoms of haemothorax, where blood fills the chest cavity, included sudden severe chest or upper back pain, severe abdominal pain, and breathlessness.

“Mr Joe’s medical records show he was experiencing abdominal pain in the days leading up to severe chest pain on April 4 since the operation.

“Given the pathologists findings, [Joe’s] medical history, and his ongoing abdominal pain since the operation, I have concerns about the care he received leading up to his death.”

The hospital said Joe’s history and other health complications made him a high-risk surgical candidate and this was explained to him.

But Tetitaha said the possibility of a stent problem was known by April 4 when Joe’s chest pain was increasing.

Clinical notes from that day set out the concerns of the doctors and the decision not to take any further investigation “due to health risks”.

The coroner said the notes did not record whether this decision was discussed with Joe, and it did not appear he had any whānau or other support, with his younger brother later indicating the family was unaware of Joe’s health complexities.

“Given the critical nature of the decision made on April 4 by medical professionals not to investigate the stent problem, Mr Joe should have been fully informed and given a choice about whether further investigation should occur.”

The coroner said there was a public interest in having the death investigated by the Health and Disability Commissioner.

“This death occurred in a public hospital. There are concerns raised about the care Mr Joe received in hospital, including whether it met the standards set out in the Code [of patient rights].”

She referred Joe’s death to the Health and Disability Commissioner for further investigation.