Over 24 hours, the woman received multiple doses of opioids before being admitted to the intensive care unit after she was found unresponsive.
Tests later confirmed she’d suffered a hypoxic brain injury with a decreased level of consciousness.
Now, Dr Caldwell, has found Health NZ Counties Manukau breached the woman’s right to have services provided with reasonable care and skill.
The deputy commissioner said even though the opioid medication was administered within normal doses, there were no clear policies in place to support safe practices for administering opioids at the hospital.
Health NZ Counties Manukau defended the case, saying the woman was assessed and managed appropriately. However, it acknowledged the case highlights the difficulties of administering pain relief intravenously.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell.
It also said it was possible that the staff didn’t make a connection between the amount of opioids they prescribed to the woman, while also administering her regular medication.
However, the woman’s brother said it is “extraordinary” that the hospital can say the standards of care were appropriate, given what happened.
Stretched ED, staffed with juniors
According to the decision, the woman went to the hospital on March 4, complaining of abdominal pain, diarrhoea and loss of appetite.
The woman had a history of psychiatric problems, including anxiety, paranoia, sleep apnoea and depression. A decade earlier, she’d been diagnosed with chronic pain syndrome.
Caldwell found that the night the woman was admitted, the emergency department was busy and staffed with juniors, who were “stretched”.
After describing her pain level as 6/10, she received intravenous fentanyl and paracetamol before being moved to the short-stay ward.
There she continued to receive regular doses of fentanyl and fast-acting oral oxycodone, as well as her usual medications, including one to treat bipolar disorder.
A CT scan and chest X-ray showed no abnormalities, and the clinical impression was that she had gastroenteritis (stomach flu).
The following afternoon, a junior doctor concluded the woman’s pain was out of proportion with clinical and radiological findings, and she had been given long-acting oxycodone.
That evening, the woman was admitted to the surgical ward with an increased pain score of 7-8/10. She was still receiving fentanyl and fast-acting oxycodone to help manage her pain, as well as her nightly medications of diazepam, for anxiety and zopiclone for insomnia.
Staff recall the woman kept asking for more pain relief, using the call bell multiple times, but say they checked her oxygen and respiration rates every 30 minutes because of the amount of medication she’d received, although this was never documented.
Staff also recalled that at 10.45pm, they refused to give the woman additional pain relief, telling her to wait until her next dose.
An hour and a half later, the woman was found by staff to be unresponsive and not breathing properly. She was given oxygen and naloxone, which reduces the effects of opioids.
Subsequent CT and MRI scans confirmed the woman suffered a hypoxic brain injury, with a decreased level of consciousness, likely secondary to opioid-induced hypoxia.
The woman was eventually discharged from the hospital at the end of March.
No longer has any quality of life
The woman’s brother told the HDC that while her underlying condition made matters complex, her mental state and function have been dramatically altered since the event, and she “no longer has any quality of life”.
Recognising the many “amazing, competent and caring individuals” who looked after his sister during her hospital stay, he told the HDC that the initial care and attention were lacking.
Acknowledging the woman was in pain, he denies that the bell was rung multiple times, recalling there was “very little interaction with staff” and says his sister wasn’t observed regularly.
Multiple doses of opioids over 24 hours
In her findings, Caldwell agreed with an internal review that the opioid medications were prescribed within normal recommended doses.
But she said there was no attempt to find another source of the woman’s pain, and the prescribing of opioids should have been overseen by a senior doctor.
“Despite Ms B receiving multiple doses of opioids over 24 hours, her pain score was documented only five times, particularly given that it was recognised that the requirement for pain relief was out of proportion to the symptoms, and Ms B continued to experience pain even when the maximum doses of opioids had been given.”
But Caldwell acknowledged the steps that the hospital had taken, including improvements in clinical documentation, review, and updates to the opioid protocol, and changes to the Medication Chart, including co-prescribing hints/advice as well as alerts and lockouts, were “appropriate remedial actions”.
She recommended Health NZ Counties Manukau apologise to the woman and her family for the deficiencies identified in the report.
Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist at the Waikato Times and RNZ. Most recently she was working as a media adviser at the Ministry of Justice.