In December 2022, the Health and Disability Commissioner received a referral from the Coroner on behalf of the man’s daughter regarding his care at Wairarapa Hospital.
HDC deputy chair Dr Vanessa Caldwell said in a report released today that Te Whatu Ora Health NZ Wairarapa breached the Code of Health and Disability Consumers’ Rights regarding the man’s care.
“Health NZ identified that procedures for consultation, referral, and transfer to ICU were unclear, visibility of the patient’s clinical status and observations during escalation attempts for the receiving ICU was limited, and no clear document existed governing handover and capacity issues.
“In my view, the lack of clarity and absence of important procedures represent a failure at the governance level by Health NZ Wairarapa.”
She found that difficulty with ICU transfers was not isolated.
“Health NZ Wairarapa identified that visibility for the receiving ICU was limited and handover during escalation attempts was unclear in this case.
“Similar issues regarding intra-regional communication and the clarity of escalation pathways were highlighted in another HDC investigation, reinforcing that these challenges are not isolated to one event.”
Man presented to GP before hospital
About 9am on January 25, 2022, the man, who is not named in the report, experienced sudden severe epigastric pain, collapsed at work and was transported to the local medical centre by private vehicle.
His GP noted he was experiencing severe epigastric pain radiating from the torso and was nauseous and had vomited. A bedside ultrasound scan identified a large gallstone.
His pain was difficult to manage despite a fentanyl patch and ketamine infusion, so a decision was made to transfer him by ambulance to Wairarapa Hospital ED.
A CT scan suggested acute pancreatitis and identified possible early blood clots in his portal vein and multiple areas in the gallbladder that could represent gallstones or small polyps.
The senior medical officer (SMO) general surgeon told HDC that it was unclear whether the inciting cause of the man’s pancreatitis was gallstones or alcohol, as he had a significant alcohol history.
He was then transferred to the medical surgical ward (MSW) for monitoring and pain management.
Over the next 24 hours, he underwent several reviews for uncontrolled pain and deterioration on the Early Warning Score (EWS) chart.
The EWS is a tool to assist clinical staff in determining appropriate actions when a patient deteriorates. It provides a score based on the patient’s vital signs and describes how care should be escalated according to those scores.
The higher the score, the more urgent the escalation pathway.
At 2.20am on January 26, 2022, a registered nurse requested a medical review of the man after his EWS increased to 5.
At 3.30am, the on-call house officer reviewed him and documented rising blood pressure, respiratory rate, and heart rate; a distended and tender abdomen; and that he was experiencing pain “everywhere”, felt short of breath, and appeared uncomfortable.
The plan was to adjust pain relief and continue monitoring him.
The man’s EWS chart reflects that, during his time in the MSW, his heart rate and respiratory rate were within the “red zone”, indicating that he was “likely to deteriorate quite rapidly”.
However, Health NZ conducted a Clinical Event Investigation (CEI) after these events and found that the ward staff house officer did not escalate the MET calls to the SMO as required by policy, and acknowledged a failure in the response to the EWS score.
Written annotations on the EWS chart did not indicate that his EWS score was 10+ or that any vital sign parameter was within the blue zone at this time, which would have required an emergency (MET) response.
First attempt at ICU transfer failed
At 9.15am, he was transferred to the High Dependency Unit (HDU) for fluids, monitoring, and pain management, with the plan that any further deterioration would require transfer to the ICU at Wellington Hospital. Clinical notes indicate that the MET call was made at 9.46am, but this was not accurately recorded on the EWS chart.
About 10pm, clinical staff reviewed the man and discussed possible transfer to Wellington Hospital ICU.
The SMO general surgeon told HDC that the three general surgery SMOs had a “high level of concern for his active decompensation”; however, they were initially told to attempt HDU management at Wairarapa Hospital and then told that Wellington ICU could not accept the transfer because of bed availability.
The man was needing to be transferred to Wellington Hospital for intensive care. Photo / Mark Mitchell
As a result, an interim management plan was made for the man to remain in the HDU with increased fluids and pain relief and to commence antibiotics.
Overnight on January 26-27, 2022, the MET criteria were met every hour, indicating ongoing clinical deterioration. However, Health NZ acknowledged that the house officer did not escalate MET calls to the SMO in the HDU.
A second CT scan was done but delayed by more than four hours.
The results showed severe inflammation of the pancreas with areas of dead tissue.
The scan also identified likely tissue damage in the liver because of reduced blood flow.
Gallstones were present, but the scan could not clearly visualise the main bile duct to rule out a blockage, so an ultrasound was recommended. The scan also showed fluid around both lungs, causing parts of the lungs to collapse slightly.
In its CEI report, Health NZ acknowledged that the decision to await a CT scan contributed to an additional delay of about four hours before ICU consultation progressed.
However, Health NZ told HDC that there was nothing on the referral to indicate that the scan was urgent and a turnover time from referral to report of 4.5 hours was acceptable for a same-day request.
The man was then transferred to Wellington’s ICU, arriving at 8.20pm.
At 10pm, the surgical team considered the man was dying from severe pancreatitis and multi-organ failure and that no surgical treatment option was available.
He died on January 27 of acute pancreatitis with subsequent organ failure.
‘Lack of clarity’ contributed to events
The CEI report found that the main issues were “all centred around a failure of process and organisational culture rather than personal failures of any individual healthcare professionals involved in [the man’s] care”.
This included observations not consistently completed, and instances where EWS calculations were inaccurate or not totalled correctly.
There was no clear procedure for consultation, referral, and transfer of a patient to Wellington Hospital ICU.
The lack of clarity contributed to limited visibility for the ICU team about the patient’s clinical status and observations, and there was no formal documentation outlining the handover process or how to manage capacity issues during transfer attempts, Caldwell said.
“In my view, these are serious departures from accepted practice in a deteriorating patient and materially reduced the reliability of the safety net that the EWS system is designed to provide.
“I also note Health NZ’s finding that staffing acuity and workload (at Wairarapa Hospital) was not a contributing factor in this case, which I consider indicates an organisational need for greater awareness of and training on the mandatory escalation pathway.”
Several changes had since been made by Health NZ to address the issues, Caldwell said.
Health NZ has been approached for comment.
“I emphasise the importance of embedding these improvements consistently across the region to support reliable, safe, and co-ordinated escalation of care for acutely unwell patients in the future.”
Caldwell recommended that Health NZ Wairarapa provide a formal written apology to the family and confirm implementation and review the effectiveness of the recommendations set out in the CEI report among other suggestions.
Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.
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