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Failure to review post operative chest X-ray (12HDC01133)
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District health board ~ Intensive care unit ~ Chest X-ray ~
Tension pneumothorax ~ Standard of care ~ Continuity of care ~
Communication ~ Rights 4(1), 4(5)
An 87-year-old man was admitted to hospital with lower abdominal
pain and vomiting black bile. Three days later a CT scan indicated
gallstone ileus and the man was referred for laparotomy surgery and
removal of his gallstone. That evening the man's condition
deteriorated and a plan was put in place for the man to be admitted
to the Intensive Care Unit (ICU) post-operatively. A pre-operative
chest X-ray indicated aspiration pneumonitis, and the man was taken
to surgery urgently.
Following surgery the man was transferred to ICU in the early
hours of the morning. During handover to ICU, the anaesthetic team
advised that the man would require a post-operative chest X-ray for
confirmation that the central venous line placed during surgery had
been placed correctly. The anaesthetic team also advised that the
man was currently having oxygenation and ventilation problems.
The ICU associate charge nurse ordered a post-operative chest
X-ray for the man. The associate charge nurse and another ICU
registered nurse assessed the man and both concluded that his
presentation was consistent with having aspirated prior to surgery
and that he was developing aspiration pneumonia.
At 3.24am radiology performed the post-operative chest X-ray.
The man continued to deteriorate and the ICU registrar maintained
regular phone contact with the consultant on call. The consultant
did not ask for the results of the X-ray. At 8.15am the ICU night
team performed handover to the ICU day team. Following handover,
the day ICU consultant implemented palliative care for the man in
consultation with his family. That afternoon, the man died.
The following day, the man's X-rays were reviewed for the first
time at a multi-disciplinary radiology meeting. A large tension
pneumothorax was visible on his chest X-ray which had not
previously been detected by any member of staff. The District
Health Board (DHB) concluded that the tension pneumothorax
contributed to and "possibly directly caused" the man's death.
It was held that the DHB failed to provide clear direction to
staff about management and review of post-operative care and failed
to undertake a timely review of the X-ray. Further, the DHB was
responsible for failures within the ICU team to consider
differential diagnoses. The DHB did not provide services with
reasonable care and skill, breaching Right 4(1). The DHB was also
responsible for the failures by its staff to adequately communicate
with each other regarding the man's condition. The failure to
communicate affected the quality and continuity of services
provided to the man, breaching Right 4(5).
Adverse comment was made regarding the ICU registrar as the
clinician with primary responsibility for reviewing the X-ray.
Further adverse comment was made regarding the day ICU consultant,
that clinicians should always ensure that they are aware of
relevant information when making a decision regarding a consumer's
care and treatment, especially when making decisions regarding
withdrawal of active treatment or commencement of palliative