Woman died in Waikato Hospital because cardiac alarm volume was turned down

By RNZ

• Waikato Hospital staff took several minutes to notice patient’s monitor alarm had been activated
• Coroner’s inquiry found the death at the hospital’s emergency department was preventable
• Health NZ said woman had extensive cardiac history and earlier detection wouldn’t have made a difference

A woman who suffered a heart attack died in Waikato Hospital because no one heard her alarm going off, a coroner has ruled.

The 84-year-old, who had been living in an aged-care facility, was admitted to the hospital’s emergency department (ED) with severe chest pain in February 2023.

While waiting for a cardiology assessment, the patient was put on a bedside cardiac monitor.

She later went into cardiac arrest, but it took ED staff several minutes to notice her monitor alarm had been activated.

The patient was found unresponsive and resuscitation attempts were unsuccessful.

A coroner’s inquiry into the death found the alarm volume had been turned down to an inaudible level. The inquiry was unable to determine who lowered the volume.

Coroner Ian Telford did not accept Health New Zealand (HNZ) Waikato’s claim earlier intervention would not have changed the outcome. HNZ Waikato said the patient had an extensive cardiac history.

But Telford said the death might have been prevented if the patient’s arrhythmia had been detected and treated more quickly.

The woman died in Waikato Hospital's emergency department. Photo / NZME

The inquiry also found the patient had not been checked on for two hours before she died.

Telford said not being seen by a nurse for more than two hours in a critical care setting like the ED was not acceptable.

“At the time of the critical event, the nurse-to-patient ratio that night was lower than the ratio recommended by the New Zealand Nurses Organisation and the College of Emergency Nurses New Zealand.”

However, Telford said he could not determine if increased staffing would have made a difference.

“Put simply, even if there were more staff on duty, they may have all similarly failed to hear or see the monitoring devices alarm.”

He recommended alarms for critical events in the hospital be audible and easily distinguished from other alarms.

He said frequent non-critical alarms were distracting and resulted in “alarm fatigue”.

He also called for medical and nursing staff to be appropriately trained on using the monitoring system.

He said HNZ Waikato had taken steps to ensure future patient safety and therefore did not refer the case to the Health and Disability Commission.

But short-staffing continued to be an issue for Waikato Hospital.

A patient who spoke to RNZ from their hospital bed said they had waited more than a month for cardiac surgery.

Last week, another patient waited more than 16 hours in the hospital’s ED with suspected internal bleeding only to be referred back to their GP.

And on Friday more than 600 nurses, midwives, healthcare assistants, students, and administration staff walked off the job at the hospital over recruitment concerns.