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Triage assessment of patient with reported exposure to meningitis; delays in treatment (12HDC01172)
Download Triage assessment of patient with reported exposure to meningitis; delays in treatment (12HDC01172) (PDF 69Kb)
District health board ~ Registered nurse ~ Senior registrar
~ Emergency department ~ Triage ~ Meningococcal meningitis ~ Delays
~ Staffing ~ Overcrowding ~ Discharge from ED ~ Right 4(4)
A young woman presented to the Emergency Department (ED) of a
public hospital with her partner. She was complaining of a sore
throat, stiff neck, headache and vomiting. Her classmate had been
diagnosed with meningococcal meningitis ten days earlier.
There was one nurse assigned to the ED waiting room that night.
The young woman was triaged by that nurse as requiring assessment
within 30 minutes (ATS category 3). The young woman waited
approximately three hours and 20 minutes to be seen by a doctor.
Due to the acuity of the ED that night, a full set of vital signs
was not taken and her condition was not reassessed while she waited
to be seen by a doctor. The young woman was diagnosed by a senior
registrar as having pharyngitis and was discharged the following
morning after receiving intravenous antibiotics overnight.
The young woman then developed a rash on her hands and legs. She
returned to the ED and was triaged as requiring assessment within
10 minutes (ATS category 2). She waited approximately 55 minutes to
be seen by a doctor, following which she was admitted to the
hospital with a primary diagnosis of meningococcal meningitis and
septicaemia, and a secondary diagnosis of Group A Streptococcal
throat infection. She received five days of intravenous antibiotics
before being discharged home.
The Commissioner concluded that a series of systemic and
individual failures led to delays in the young woman's medical
assessment on both presentations to the ED which were suboptimal in
the circumstances. The young woman exceeded the recommended waiting
time for a factor of four on each occasion, which was unacceptable
in the context of suspicion of significant sepsis both initially
and on representation.
It was held that by failing to provide adequate staffing and
resources to enable its triage procedures to be implemented
effectively and safely, the district health board failed to provide
services in a manner that minimised the potential harm to the young
woman and, accordingly, breached Right 4(4). Adverse comment was
also made about the triage nurse and the registrar.
The Commissioner recommended that the district health board
review its triage policy and undertake an audit of the various
changes made since this incident.
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