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Inadequate monitoring of man with cardiac issues

Health and Disability Commissioner Anthony Hill today released a report finding Taranaki District Health Board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for providing a very poor standard of care to a 68 year old man who presented to a public hospital with chest pain.

In 2015, the man was admitted to the emergency department and blood tests and an electrocardiogram showed that he had suffered a heart attack. He was admitted to a general medical ward, where he was monitored via remote cardiac monitoring, and commenced on blood-thinning medications.

The man was given several sprays of glyceryl trinitrate (GTN) to relieve his chest pain. Mobilisation soon after the use of GTN carries a risk of falling over. Despite this, the man’s risk of falling was not managed adequately, and he fell and injured his head. When staff were alerted to the man’s fall, they did not respond appropriately. The information regarding the man’s fall and head injury was held by some staff, but not communicated adequately to those who needed to know.

Blood thinning medication continued to be administered to the man by some nursing staff, despite knowing that he had sustained a head injury, and without ensuring that he had been reviewed by the medical team. When the man began to deteriorate, medical review was not sought with clarity, and decisions about the medical review were not recorded.

Later that evening, nursing staff found that the man had vomited, was breathing abnormally and was non-responsive. An urgent CT scan showed a large brain bleed and following a discussion with his family, the man received palliative care and sadly died in the early hours of the next morning.

Mr Hill stated that the while the information required to treat the man correctly was contained within the hospital system, staff failed to do so, with tragic consequences.

"The system lost sight of the man through this process," Mr Hill said.

"Attention to the most basic aspects of monitoring, assessment, communication, and critical thinking were noticeably absent. This is well below the standard expected of hospital-level care in New Zealand. While staff may have been busy, they had the opportunity to consider the care of this patient, and simply failed to do so adequately - this was a collective failure of the system and the people operating in it, not the fault of any one individual. Nonetheless, the man’s experience resulted from a pattern of poor care, which reflects a sobering collection of suboptimal features."

Mr Hill made a number of recommendations including that the DHB review its communication tools to ensure accurate handover between shifts, provide evidence of a new alert system flagging patients who are receiving blood thinning medications, conduct an audit to assess whether patients who have experienced heart attacks have been appropriately transferred to the critical care unit and conduct an audit to assess the appropriateness of the electronic notification tool used to contact medical staff.

The DHB has been referred to the Director of Proceedings.

The full report for case 16HDC01028 is available on the HDC website.


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