'Wrong leg' error factor in woman's death - Coroner

File photo / The Aucklander

Alarming hospital administration errors led to confusion over which of an elderly woman's legs needed an operation before her surgery was cancelled and she was sent home, dying days later, a coroner says.

Lower Hutt woman Yvonne Paula Watkins, 89, died of heart failure on September 2, 2008, four days after the hospital cancelled an angioplasty to widen blood vessels in her left leg affected by atherosclerosis, and sent her home.

Coroner Ian Smith said in his findings released today that a priority operation at the hospital on August 27 meant Mrs Watkins' surgery had to be pushed back a day, but when she was taken to theatre, medical staff began preparing her right leg instead of her left.

Mrs Watkins intervened, telling doctors it was her left leg which was to have the procedure, and after confusion over the omission of which leg it was from administrative notes, the operation was cancelled and she was sent home the following day, with her readmission scheduled for October 16.

Her death four days later from heart failure was unrelated to her leg condition.

She had pre-existing medical conditions including asthma and a number of major heart complaints, including chronic obstructive pulmonary disease and angina.

Capital and Coast District Health Board apologised to Mrs Watkins' daughter, and acknowledged the course of events had been "clearly unsatisfactory".

But the board said there was little to suggest her time in hospital was a contributing cause.

The cause of the hospital's errors were "poor documentation and communication", but the board had since introduced a safety protocol for preventing such events.

Mr Smith said it was "pleasing" the board had adopted the protocol, but it was alarming that it had taken until at least 2008 to do so.

He raised "serious doubt" about documentation at the hospital.

"It is indeed worrying that in this sophisticated computer age such events are occurring,"

He disagreed that the events at the hospital would not have contributed to Mrs Watkins' death.

Being mentally and physically prepared for an operation, then being stood down, then having to intervene and explain that staff were preparing the wrong leg, and finally being discharged meant her wellbeing was "very highly likely impacted", Mr Smith said.

"She would have been under enormous stress."

He found that Mrs Watkins died of acute left ventricular failure.

- NZPA