Deputy Health and Disability Commissioner Dr Vanessa Caldwell said the serious incident resulted in the man sustaining a life-altering injury.
In a report released today, Deputy Health and Disability Commissioner (HDC) Vanessa Caldwell commended Health NZ for the steps taken since to address what happened, and for recommending that the patient and his family make a complaint to the HDC for independent review.
“Nevertheless, a serious incident resulted in [the man] sustaining a life-altering injury,” she said in her report.
No evidence of spinal injury in car accident
The man was rushed to Auckland Hospital’s emergency department with multiple internal injuries and broken bones, but no evidence of a cervical spine fracture following a car accident in 2022.
He was then admitted to a critical care unit and then transferred to the general surgery ward under the trauma service.
Doctors were concerned about the man’s ongoing increased respiratory and heart rates.
A scan showed moderate build-up of fluid in his chest and lungs, which a senior trauma specialist said needed to be drained.
Health NZ policy around the management of the procedure stated that, unless in an emergency, all chest drains for fluid aspiration should be guided by real-time radiology imaging.
Caldwell said for reasons Health NZ had been unable to determine at review, the imaging request could not be accommodated by the interventional radiology team.
As an alternative, a chest ultrasound was scheduled to indicate where the drain should be inserted, but it didn’t go ahead because the man was in too much pain to be moved.
The procedure was rescheduled for the following day.
‘Seldinger’ technique at bedside
A decision was then made to insert the chest drain at the bedside using what was known as the Seldinger technique.
The method involved inserting a hollow needle into a body cavity. A round-tipped guidewire was then inserted through the needle, which was then withdrawn, leaving the guidewire in place. A catheter was then placed over the guidewire into the cavity.
It was described as the preferred method in this instance because it was less painful and less invasive.
A trauma registrar, under the supervision of two trauma fellows, made two attempts at inserting the chest drain but the guidewire and chest tubes did not pass smoothly.
There was no nurse present, despite a Health NZ management policy which stated a nurse should be present to help and to monitor pain, distress, and clinical deterioration.
The two trauma fellows, who were a surgeon and a physician, then took over, and dark, “old-looking” blood was aspirated.
While suturing the drain to the man’s chest wall, he became “very sweaty”.
Code red turns to code blue
The emergency bell was activated, and a nurse noted that the man had high blood pressure and a faster-than-normal heart rate.
The chest drain collection bottle had filled with blood and was clamped by the second trauma fellow to prevent further loss.
The man’s condition deteriorated and a code red medical emergency was called.
Caldwell said it was described as “chaotic, noisy, and without a clear code leader” or any detailed communication or indication of the volume of blood the man had lost.
The on-call trauma senior medical officer upgraded the situation to code blue, meaning the patient was in cardiac or respiratory arrest.
By this point, the man had lost about four litres of blood and had lost cardiac output, Caldwell said.
Emergency surgery
He was given at least five minutes of CPR when his aorta was clamped for about five to seven minutes, before he was rushed to theatre for emergency surgery when it became apparent the drain was in the right lobe of the man’s liver.
A CT scan confirmed it had travelled through the liver and into the middle of a nearby vein, with the tip of the drain in a major vein.
A serious adverse event review found the drain had been inserted incorrectly, leading to massive blood loss, shock and cardiac arrest.
Caldwell said that as a result, the man developed ischaemic bowel and spinal cord injury, causing paraplegia from mid-back level, and suspected mild hypoxic brain injury.
She said there was no written informed consent documented for the chest drain insertion.
Moderate to severe departure in standards
Independent advice from trauma surgeon Grant Christey found there were moderate departures in the standard of care on multiple points.
However, a severe departure from standards was found in resuscitation efforts hindered by the environment, inadequate leadership, a lack of nursing staff who could quickly locate necessary equipment, and poor communication.
Christey also found a moderate departure in standards by the surgeon and physician at the time of the incident; one being responsible as the senior clinician and the other for not speaking up to prevent the error.
He also found a moderate departure in the standard by the surgical registrar for not speaking up when he thought the procedure was unsafe.
Caldwell said this was, however, mitigated by his handing care over to the more senior clinician when he felt out of his depth.
Health NZ disputed Christey’s advice and some parts of the provisional findings, Caldwell noted.
Health NZ also said the registrar could not have been expected to speak up about an error he did not know about at the time.
Among a list of recommendations, Caldwell said, as per Christey’s advice, Health NZ was to update its chest drain policy.
She also recommended an audit of 30 patients who had undergone a chest drain insertion within the last year to ensure that the informed consent form was completed adequately.
Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.