A recommendation from the review included the need to address the night-time culture of “do not disturb” the offsite call-back staff to protect their down time.
Deputy Health and Disability Commissioner Vanessa Caldwell said in her opinion the findings of the review highlighted the “systemic deficiencies” that led to the failures in the man’s care.
Decline following surgery
The patient underwent elective surgery on July 16, 2019 to restore bowel continuity, following earlier surgery on his small intestine to create a stoma through his abdominal wall.
He was then meant to have been sent to the recovery ward but was heavily sedated on morphine and so was given medication to reverse the effects of the opioid and was admitted to the ICU for observation.
Early the next morning, he was assessed by a junior doctor because his blood pressure was low and was given intravenous fluids.
He was then reviewed by an anaesthetist and was given a unit of red blood cells because bloody fluid was found in his abdominal drain and his haemoglobin levels had dropped, Caldwell said.
She said he was fully awake and his blood pressure remained stable, although he was noted to be sleepy.
The next day, the man’s haemoglobin was noted as stable, he was alert and tolerating clear fluids orally.
He was assessed by a doctor that afternoon and advanced to a light diet.
‘Agitated and restless’
On July 19, nursing notes stated he had been “agitated and restless” all night and that his respiratory rate had increased, with readings ranging from 20 to 28 breaths per minute.
At 5am, nursing notes documented he was coughing up sputum and green fluid, indicating that his condition was deteriorating, Caldwell said.
Health NZ told HDC that, at the time, the early warning score pathway was used in other departments but not in the ICU.
The pathway recommended monitoring vital signs, such as respiratory rate, every four hours for patients with acute illness and up to every hour if the patient was showing signs of deterioration.
Caldwell said clinical notes showed the man’s respiratory rate was taken seven times between 7pm on July 18 and 5.30am on July 19.
A Health NZ review into the death of a man following surgery said problems in the ICU at Gisborne Hospital were deeper than just “safety out of hours”. Photo / Liam Clayton
Between 6am and 8.30am that day, his respiratory rate was taken five times, with readings between 28 and 40 breaths per minute.
A house surgeon who reviewed the man noted he was short of breath, cold and clammy.
The doctor also noted he was possibly experiencing aspiration (condition in which food, liquids, saliva or vomit is breathed into the airways) or pulmonary embolism (life-threatening blockage in a lung artery).
The doctor recorded a plan for intravenous antibiotics, a chest X-ray and further blood tests, including one which detected fragments released when the body broke down a blood clot, plus anaesthesia and surgical review.
Investigations pathway ‘unclear’
According to nursing notes, the man was given further oxygen at 7.35am but that he was “yet to have” a chest X-ray and/or the further blood tests.
Caldwell said it was unclear from the information available whether the further investigations were ordered.
In addition, senior staff other than the anaesthetist (such as a senior medical officer or a surgeon) were not contacted to review the patient.
Caldwell said the anaesthetist on call reviewed the man at around 8.45am, by which time he was in respiratory distress and complaining of increasing back pain.
While a breathing support device was being set up, the man vomited and went into cardiorespiratory arrest.
CPR was carried out for 20 minutes but was unsuccessful, Caldwell said.
Health NZ’s Serious Event report found a “lack of clear responsibility or ownership” for patients in the ICU and a lack of clarity around how, and to whom, a deteriorating patient in ICU should be escalated.
It also found there may have been barriers to staff contacting the on-call senior medical officer to escalate the man’s care. The on-call senior medical officer seemed to have been unaware of the man’s poor state.
The review also found there was a delay in seeking a chest X-ray when the man’s condition was deteriorating. Staff may have been delaying ordering such investigations to “protect the resource”, Caldwell noted.
It said problems within the hospital’s ICU at the time included a lack of detailed medical input and direction, deficient nursing management and leadership, a lack of nurse education and “best practice” and a lack of policy, procedures and guidelines.
Health NZ told the HDC that it was unable to locate a “recommendations implementation plan” because key personnel had since left.
The plan would have included all the recommendations, who was responsible for their implementation and the timeframe for completion, Caldwell said.
Health NZ in breach of code
She found Health NZ to be in breach of the Code of Health and Disability Services Consumers’ Rights over failures in the man’s clinical care, and because Health NZ had acknowledged a lack of clear responsibility and ownership for patients in the ICU.
“In my opinion, there was a systemic failure to ensure that [Mr B’s] deteriorating condition on the morning he passed away was recognised and appropriately escalated and investigated.”
Caldwell said Health NZ provided evidence that some recommendations had been implemented, but given that six years had passed since the internal reviews, she was concerned that several recommendations were yet to be implemented and it remained unclear what action was being taken to complete them.
She recommended that Health New Zealand Te Whatu Ora Tairāwhiti provide an update on its recruitment of an ICU educator and clinical coach roles and a plan to increase skilled nursing levels in ICU within six months.
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.