In response to provisional findings, the man and his family told the HDC that he had remained “mobile, ambulant, and neurologically functional, and that the catastrophic deterioration occurred only after medical intervention at North Shore Hospital”.
His family said his loss of independence had “devastated him” and his diagnosis has had a profound impact on many aspects of the family’s lives.
The man, referred to as Mr A, arrived at North Shore Hospital emergency department with a headache, pain in his upper thoracic spine and a contusion to his head, but said he had not experienced vomiting or limb weakness.
He said immediately after the fall, he was able to stand independently, maintain full balance and co-ordination, bend without assistance and walk unaided.
He had a condition called ankylosing spondylitis (AK), a chronic inflammatory arthritis that primarily affects the spine and sacroiliac joints and often causes lower back pain and stiffness, and potentially increases the risk of fractures.
The man was given a wheelchair, and later transferred himself to a stretcher, though the ED clinical notes state he was log-rolled – a technique used to turn a patient with a suspected spinal injury, keeping their head, neck and spine in neutral alignment – on to the stretcher.
An adverse event review by Health NZ said a yellow lanyard had been placed around his neck, signalling a potential neck injury, but the man said he didn’t recall it, nor remember being log-rolled.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found, based on clinical advice, that a lanyard was not standard practice, and it was more likely that neither the lanyard nor the log-rolling had taken place, but these did not amount to a departure from accepted practice.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell.
While waiting for a CT scan, the man reported numbness and burning in his right ring finger, which was examined by the ED registrar, who noted the finger had a full range of motion.
ED specialist Dr Richard Highstead said the report of new sensory changes in his finger should have prompted reassessment of the neurological examination.
Highstead advised that the man’s neurological evaluation was incomplete during an ED registrar’s examination, and “was not adequately addressed in the second instance when Mr A developed new pain in his finger”.
Caldwell agreed this constituted a moderate departure from accepted practice.
More than three hours after arriving at hospital, he was taken for a CT scan.
Again, there were conflicting accounts about how he got on to the CT table, with the man and the clinical notes stating he got on to the table by himself, but the adverse event review stating six staff in the radiology department log-rolled him on to the CT table.
Again, Caldwell was inclined to rely on the contemporaneous documentation, supported by the man’s recollection, and found “it more likely than not that Mr A mobilised independently to the CT table”.
An attempt was made to lay him flat, which he said resulted in severe pain, and he developed severe pain in the back of his neck and numbness.
The clinical notes stated the man reported tingling in his right C6, tingling in his arms and legs, and that he was unable to move his legs or wiggle his toes on demand.
Shortly after lying flat, he had signs consistent with a spinal cord injury and the CT scan showed a fracture-dislocation of the C6-7 with more than 10% displacement.
The man was transferred to Middlemore Hospital for ongoing care and is now tetraplegic.
Highstead advised that the man’s spine tenderness when first examined and new finger sensory changes, given his AK condition, made his “mobilising on to the CT table concerning”.
He noted the man was over 65, suffered a fall with associated loss of consciousness and was experiencing spinal discomfort in the setting of AK, and went on to develop new neurological changes while in the ED.
Highstead said the man should have been under spinal precautions and should not have mobilised on to the CT table.
“Dr Highstead advised that this failure represents a severe departure from accepted standards, and I agree,” Caldwell said.
However, both Highstead and the external AER reviewer agreed that it was likely the spinal cord injury occurred when the man was laid flat on the CT table and that earlier recognition of his symptoms would not have changed his outcome.
Given the likelihood that the injury occurred when he was lying flat in the CT scanner, Caldwell considered the appropriateness of ordering a CT scan.
“I have considered the fact that the AER and Health NZ’s independent reviewer agreed that the CT scan was a necessary step in further investigating Mr A’s symptoms, and I note that Dr Highstead has not found the ordering of a CT scan to have been inappropriate in this case.
“On that basis, I accept that it was appropriate for clinicians to order a CT scan to further investigate Mr A’s symptoms.”
However, in “both failing to complete a comprehensive neurological examination in light of Mr A’s presentation and risk factors and by allowing Mr A to transfer independently to the CT table despite his spinal tenderness and new onset of neurological symptoms, Health NZ failed to provide services with reasonable care and skill to Mr A”.
Health NZ made several changes after the events and its subsequent AER, including more education for all ED, radiology and transit care staff regarding the risk posed by AK and other fixed-spine deformities.
Ongoing education is provided regarding C-spine injuries and maintaining C-spines in a neutral position, and the radiology department developed a protocol for positioning patients with fixed-spine deformities requiring a supine position in CT, especially those requiring assessment for possible C-spine injury.
Training is consistent regarding moving patients with possible spinal injuries; log-roll and spinal precautions training is mandatory for all staff involved in moving patients.
Health NZ was required to provide the man and his family a written apology.
Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.
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