Coroner Alexander Ho, in a decision just released, found that there were “missed opportunities” to closely monitor and objectively track any developing infection in the wound in the weeks before Barton died.
“My inquiry ... identified confusion, not only among the health professionals involved in Mrs Barton’s care, but also between the experts and organisations I consulted,” the coroner said.
They were confused about whether the district nursing team was solely responsible or had shared responsibility with the GP for wound care, and the times when sole or shared responsibility applied.
Coroner Ho said that a swab taken 10 days before Barton died identified bacterial growth in the wound.
However, neither the district nurses nor the GP, who was unaware a test had been ordered, reviewed the result.
The GP had not been alert to an entry in the clinical notes indicating concerns about the wound. The doctor was also of the view that the wound was being managed by the district nurses.
The nurses were not automatically notified of the test result becoming available electronically – they generally received a paper copy of the result one or two weeks after the test.
The district nurse who took the swab did not record in the clinical notes that a test had been ordered, limiting the knowledge of the other nurses that a test result was outstanding.
“The manner in which the district nurses recorded the objective details about the leg wound differed between nurses,” the coroner said.
“This compromised subsequent nurses’ ability to track the progress of the wound and its recovery.”
Coroner Ho said the frequency with which the dressing was changed between November 15 and 19 was inappropriate to manage the wound.
“Mrs Barton was visited by five district nurses over seven visits,” the coroner said.
“I consider that identification of any deterioration in her wound and trends in her care progression, including her treatment and the response, would likely have improved with a single district nurse or smaller group in attendance.
“This reflects the proposition that personally acquired knowledge will usually result in more continuity and a better outcome.”
Coroner Ho made recommendations about the consistent recording of information, that a single district nurse or a smaller group deal with a patient, and for clearer lines of communication and electronic reporting of test results.
Health agency Te Whatu Ora Hawke’s Bay said it extended its deep condolences to Norma Barton’s family and “sincerely apologises” for its part in the events leading to her death.
Its chief nursing officer and director of patient safety and quality, Karyn Bousfield-Black, said the agency accepted the coroner’s findings and had implemented his recommendations.
This included changing the district nursing model to a team nursing approach within small geographical areas, to ensure continuity of care for patients.
It had also made changes to community nursing documentation and policies to increase the frequency of wound assessments.
It was investigating better communication methods to support GP updates via a digital platform.
“Te Whatu Ora in Hawke’s Bay will meet with family/whānau to discuss the care of their loved one, in an open disclosure format, if this is the wish of the family,” Bousfield-Black said.
