A report into a Taranaki woman's death found it was linked to multiple failures in her care post surgery. Photo / NZME
A report into a Taranaki woman's death found it was linked to multiple failures in her care post surgery. Photo / NZME
A report into a woman's death following surgery for kidney stones has found it was linked to multiple failures in her care.
The woman, aged in her 60s, died of complications linked to sepsis which was initially not recognised. A report by the Health and Disability Commissioner into care provided by the Taranaki District Health Board in 2019, found delays in follow-up surgery, in recognising sepsis after the surgery was performed, and in escalating her condition to senior medical staff when she deteriorated.
The Deputy Commissioner considered the failures were not the result of isolated incidents involving one or two staff members — they began at the time the woman was referred for her follow-up surgery, and involved at least six different staff members, both doctors and nurses.
As such, she found that TDHB breached the right to services of an appropriate standard within the Code of Health and Disability Services Consumers' Rights.
A report into a Taranaki woman's death found it was linked to multiple failures in her care post surgery. Photo / NZME
The woman had a medical history that included type 2 diabetes, high blood pressure, and asthma. Events unfolded after she arrived at Hawera Hospital's Emergency Department with acute abdominal pain, and subsequent surgery for kidney stones.
She was then transferred to Taranaki Base Hospital by ambulance for further investigation and treatment.
A CT scan confirmed an obstructing kidney stone. She was admitted and surgery was performed to bypass the blockage.
She was then sent a referral to be placed on the waiting list for a ureteroscopy lithotripsy to treat the kidney stones. The referral noted that the priority was "routine" and listed a clinically appropriate timeframe for the surgery as within four weeks.
Ten weeks later the woman's GP clinic sent an urgent urology referral to the DHB as she had not received a date for her follow-up lithotripsy, but was in significant pain. She presented back at Hawera ED with flank and abdominal pain, which had been ongoing since the stent surgery.
She was given pain relief, and admitted to Hawera Hospital overnight. A plan was made to discharge her with pain relief, antibiotics, and a follow-up clinic appointment.
A week after that appointment the woman was back in Hawera ED, with pain she described as unbearable. She was given pain relief, discharged, and told she still did not have a date booked for the follow-up surgery.
In a subsequent letter to the family, the DHB said the focus of the woman's medical management on her second and third assessments at Hawera ED was different to her first. By then – following diagnosis of kidney stones and insertion of a stent, the main goal of treatment was to manage her pain until such time as lithotripsy could be done.
The woman was then taken by her increasingly frustrated husband and son to Taranaki Hospital's ED with abdominal pain, stinging on urination, nausea, and hot/cold sweats.
The DHB stated that the severity of illness at this time prompted the need for further diagnostic investigations, which at this point indicated the need for acute surgery. The lithotripsy occurred the following day, when the woman's ureter was found to be very inflamed, and multiple (kidney) stones were found and fragmented.
During post-surgery checks the woman reported the pain was less severe than before, but different in nature. Neither was it significantly responsive to opioid pain relief.
The woman's Early Warning Score (EWS) which had been fluctuating between four and six, was soon calculated by a nurse to have reached 10 - immediately life-threatening critical illness, due to a high heart rate, low blood pressure and a reduced level of consciousness. At this point the pathway mandated that a 777 or "pre-arrest" call was to be made, which triggered a response from the Medical Emergency Team.
But a 777 call was not made on this occasion, for a list of reasons, including failure by a nurse to recognise the seriousness of the situation.
The woman was monitored over the following several hours, over which time her condition fluctuated until late at night it deteriorated again, at which point a 777 call was made. The woman was suspected of having sepsis and was soon after taken to the high dependency unit.
Blood cultures returned a diagnosis of fungaemia, and the woman was treated with antifungal medication, sedated, intubated, and ventilated.
Over the following days, discussions were held with the woman's family about her diagnosis and poor prognosis, but she continued to deteriorate, and died in hospital.
The deputy commissioner's report said the reason the woman had not received the surgery earlier than she had was "almost certainly" capacity. In 2019, the DHB had only one full-time urologist, and that even with two full-time urologists employed in 2021, it remained a challenge to deliver surgery within the Ministry of Health Guidelines.
The DHB said that it was a known organisational risk which was currently being monitored by the surgical directorate.
The Deputy Commissioner has now referred the Taranaki District Health Board to the Director of Proceedings.
A list of recommendations include that the DHB provide evidence of its EWS education campaign and roll-out programme for staff; roll out a "speaking up for safety" campaign to all nursing staff, to ensure that nurses are supported, taught, and encouraged to place a 777 call or amplify their concerns around patient management to senior medical staff.
