Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Complaint
The Commissioner received the following complaint from the complainant, Ms B, about services provided to her late daughter, Miss A, at the public hospital:
On 17 July 1999 Miss A was admitted to the public hospital with an acute illness. During her time in the public hospital Miss A was not provided with care of an appropriate standard. In particular:
House Surgeon, Dr F
- Dr F was caring for Miss A while she was in the Accident and Emergency Department. Dr F was not present with Miss A for most of that time and he offered minimal treatment and advice.
- Dr F did not request assistance from a more senior physician when Miss A's condition began to deteriorate rapidly.
- Ms B had to help the nurse to insert a tube into Miss A's airway because Dr F was not present.
Anaesthetist, Dr E
- Dr E left the Intensive Care Unit (ICU) without reading urgent blood test results.
- Dr E failed to take appropriate action following signs that Miss A may have been suffering from a viral infection rather than a head injury. Miss A had a high temperature and a raised white cell count, and a CAT scan had discounted the possibility that she had a head injury.
- Dr E did not take appropriate action after noting that Miss A was possibly suffering from meningitis. He only noted meningitis as a possible diagnosis in her clinical records and noted that a lumbar puncture should be performed in the morning. He did not verbally communicate this information to anyone so that action could be taken immediately.
- Dr E did not communicate with Ms B, Miss A's mother, about her daughter's condition and treatment options before he left the ICU. Dr E's attitude towards Miss A's care was too casual.
- Miss A's condition deteriorated significantly, but Dr E only returned to the ICU to reassess Miss A after distressed ICU staff had telephoned him twice.
Hospital and Health Services Ltd
- The Quality Assurance Review carried out by Hospital and Health Services following Miss A's death was inadequate. In particular:
- Key staff involved in Miss A's care were not spoken to during the review. This included the Accident and Emergency nurses, an ICU nurse and Dr F. The report stated that these people were not available, but they had not actually been approached for comment.
- The review identified several problems with systems at the public hospital, but Hospital and Health Services has taken no action to correct the problems identified.
Investigation Process
The complaint was received by the Health and Disability Commissioner on 2 December 1999 and an investigation began on 2 February 2000.
Information was received from:
Ms B Complainant / Miss A's mother
Mr C Miss A's step-father
Dr D Chief Medical Advisor, Hospital and Health Services
Dr E Provider / Anaesthetist
Dr F Provider / House Surgeon
Ms G Duty Manager, Hospital and Health Services
Ms H Emergency Department Registered Nurse
Mrs I Registered Nurse
Mr J Intensive Care Unit Registered Nurse
Ms K Intensive Care Unit Registered Nurse
Dr L Paediatrician
Dr M Radiologist
Advice was obtained from an independent anaesthetist/intensivist and a specialist in emergency medicine. The Ministry of Health website was accessed. Relevant medical records were also reviewed.
Information Gathered During Investigation
On Wednesday, 14 July 1999, 14-year-old Miss A had an accident during a physical education lesson at her school when a weight bar was dropped and clipped the bridge of her nose. Miss A was not seen by her GP or the school nurse but continued to go to classes. The complainant, Ms B, said that Miss A may have had a headache on Wednesday and Thursday but she took Panadol, appeared to be okay and continued to go to school.
Miss A was concerned that she may have fractured her nose in the accident, so on Friday 16 July her mother took her to the public hospital to see an ENT (ear, nose and throat) surgeon, Dr N. Dr N examined Miss A and confirmed that there was nothing wrong with her nose. The clinical notes from the ENT Outpatient Clinic record that Ms B telephoned Dr N on Friday morning and Dr N saw Miss A at 1:45pm that day. He noted that Miss A seemed well, was in her school uniform, and her nose was swollen but not deviated (disfigured). No treatment was given at that time. Ms B was to telephone him the following week if she had any further concerns.
Ms B explained that on Friday afternoon after school Miss A complained of a headache. She went to have a sleep and felt better when she woke up. Miss A was hungry and ate a good dinner but was quite irritable that evening. She worked on the computer and watched television before going to bed.
Ms B woke up around midnight and heard Miss A vomiting. Miss A looked very unwell, was vomiting and complained of a severe headache. Ms B worked at the public hospital in the town (as an enrolled nurse and trainee anaesthetic technician), so she telephoned staff in the Emergency Department (ED) to ask for advice. Ms B spoke with a registered nurse, Ms H, and explained Miss A's condition and the head injury she had sustained at school. Ms B stated that Ms H told her that it was unlikely Miss A was suffering from concussion as the accident had been 36 hours earlier, and that ED was not busy that night.
Ms B said that she and her husband (Miss A's stepfather), Mr C, decided to take Miss A into ED at the public hospital to have her checked out. Ms B said that she was unsure what was wrong with Miss A but knew that she was definitely unwell. It is a 45 minute drive on metal roads from their home to the hospital, so their decision to take Miss A to hospital was not one that was made lightly.
Ms H was working the 11:00pm to 7:00am shift in ED on the night of 16/17 July 1999. Ms H confirmed that Ms B rang ED just after midnight, as she wanted advice about Miss A, who had woken vomiting with a headache and feeling generally unwell. Ms B asked how busy ED was that night and Ms H replied that it was a reasonably busy night with a steady workflow. Ms H consulted with house surgeon, Dr F, who advised bringing Miss A into hospital for assessment. Ms H told Ms B that she could bring Miss A into the hospital if she wanted to, or she could give Miss A some Panadol and wait and see what happened. Ms H and Dr F were aware that Ms B and Miss A lived in a remote area with no medical services nearby. Ms B phoned back 10 minutes later and said that she was bringing Miss A into hospital. Ms H said that Miss A's headache was described as mild by Ms B in the first phone call and was not emphasised as being severe. Ms B disagreed: she would not have undertaken a 45 minute journey on metal roads in the middle of winter for only a mild headache.
Ms B said they arrived at ED at about 1:30am. During the journey to the hospital Miss A vomited again and had trouble holding her head upright. Upon arriving Ms B and Mr C needed a wheelchair to take Miss A inside, as she was no longer capable of walking. Mr C had commented to Ms B that Miss A's bedding had been soaked with sweat and she was very hot to touch. Miss A was not at all talkative and complained of a terrible headache and nausea.
Ms H said that when Miss A arrived she looked completely miserable, was sitting in a wheelchair and did not want to talk to anyone. Ms H said that Miss A looked like a typical miserable teenager who had been vomiting. Ms H thought that Miss A went to the toilet on arrival at ED and may have vomited again at that time. Miss A was placed into a cubicle opposite the nurses' station.
Ms H assessed Miss A's condition and triaged her as a level 3 or 4 patient. At the public hospital ED patients are triaged by a registered nurse, who requests senior assistance from a consultant or registrar on call at home if the patient is triaged as status 1 or 2. The 'Triage Decision Protocol for Initiating Trauma Calls' provided by Hospital and Health Services defines the status of patients as follows:
|
- Deceased | |
|
- Critical Potential to deteriorate Potential to deteriorate |
Very unstable Extreme |
|
- Serious Patient condition Potential to deteriorate |
Unstable Highly likely |
|
- Moderate Patient condition Potential to deteriorate |
Stable Likely |
|
- Minor Patient condition Potential to deteriorate |
Stable None |
The protocol also states that for all status 1 and 2 patients, or if the patient's Glasgow Coma Scale Score (GCS) is less than 13, systolic blood pressure is less than 90mmHg, or if certain injuries are present, a trauma call should be made to request senior medical assistance. (The GCS is used to measure the level of consciousness. A score of 15 means the patient is fully conscious, more than nine rules out coma, and a score of less than seven indicates a coma.)
Ms H stated that at 1:45am Miss A's initial blood pressure was low (74/49), her pulse was normal (84 beats per minute), she was breathing at 14 respirations per minute and her temperature was 37 degrees Celsius. Miss A's weight was 46kg, blood glucose level was 10 and her GCS was 13/15.
Ms H stated that Miss A was talking appropriately in monosyllables but not in depth, and she had no objection to her pupils being examined with a small torch. Ms B explained to Ms H that three days earlier Miss A had had an accident at school where a weight bar fell on her nose. Ms B did not know whether Miss A had lost consciousness at any stage.
Because Ms B was concerned that the temperature reading was inaccurate (as Miss A had been hot and sweaty), she took Miss A's temperature again with a thermometer under her arm. This registered 37 degrees. Ms H said the thermometer she used initially was tympanic (used in the ear), and is normally very accurate. Ms H said that at the time she commented to Ms B that thermometers are sometimes inaccurate, but in retrospect she feels this was not the case. Ms H did not think that Miss A felt hot to touch.
Ms H advised me that when Miss A arrived in ED her condition did not require immediate attention from a doctor. Miss A then started to get restless as her level of consciousness began to drop. However, Ms H commented that when teenagers are unwell they tend to back off and communicate less than usual. She therefore took no further action at that point.
Dr F was the house surgeon on duty in ED that night. Dr F trained in England, graduating from the University of London in 1992, and came to New Zealand in May 1999. He was employed in ED at the public hospital as a senior house officer (SHO) from 24 June 1999 until 29 August 1999. Dr F advised me that when he first arrived at the public hospital one ED consultant was on holiday and the other consultant was not present. A registrar showed Dr F around ED and pointed out where things were kept. This took about 30 minutes. Dr F said that he thought that policies and manuals containing standard ED procedures existed, but he does not recall seeing these manuals or being shown them. Dr F explained that when he needed to know how to do something, he would generally ask the nursing or medical staff for advice.
Hospital and Health Services advised me that when Dr F arrived at the public hospital he had two days' orientation on 24 and 25 June 1999. He was rostered on duty in ED on those days, but was superfluous to usual staffing requirements. Hospital and Health Services explained that doctors get orientated physically into departments and are expected to familiarise themselves with the protocols, clinical guidelines and procedures manual, with input from the Clinical Director; in ED Dr F was given an orientation document detailing requirements, conduct admission policy and education. Hospital and Health Services stated that the Clinical Director discusses the document's content with each SHO during their first week of employment, but could not confirm whether this was done with Dr F. Dr F began working night shifts on 12 July 1999.
At 2:00am Dr F saw Miss A after Ms H's triage examination, which was approximately 20 minutes after she arrived in ED. Dr F stated that Miss A's history was obtained from Ms B rather than from Miss A herself and that he was told Miss A had had a blow to the head two days earlier with no loss of consciousness and an increasingly severe headache. Dr F stated that Miss A had normal observations for blood glucose, oxygen saturation, respiratory rate, heart rate and temperature, although her blood pressure was initially low. The clinical notes record that at 2:00am Miss A's pupils were equal and reacting with light, size 2, and that her GCS had deteriorated to 10/15.
Dr F examined Miss A between 2:00 and 2:15am and wrote his notes up at 2:45am. He recorded the history of Miss A's head injury two days earlier, her increasingly severe headache since then and the ENT review concluding no fracture of her nose. He noted that there was no cerebro-spinal fluid leaking from Miss A's nose, which would have indicated a definite skull fracture. Dr F also noted that Miss A's headache was now worse, she had deteriorated since arriving home from school, had vomited and was no longer speaking. He specifically noted that there was no rash present and her neck was not stiff. Ms B subsequently disagreed with Dr F's assessment, in that Miss A's condition had deteriorated since her arrival in ED and she had not vomited again. Dr F described his examination and conclusions as follows:
"Examination of the patient was unremarkable with no signs of respiratory problem or shock. Her BP recorded by myself was normal at 112/72. Skull examination revealed no evidence of a skull fracture and Brudzinski Sign was absent with no neck stiffness. Abdominal examination I recall was not abnormal with no evidence of peritonitis (not recorded in the notes).
I considered the patient to have a deterioration in consciousness probably due to a space occupying lesion, most likely a haemorrhage or perhaps a brain tumour. I felt meningitis was unlikely in view of the history of mild head trauma, normal temperature and absence of haemorrhagic rash or neck stiffness. I do not recall any history of contact with meningitis from her parents but did not specifically ask for this.
I decided the patient needed an urgent CT scan and asked the radiologist at 3:05am to come in from home. Her GCS was at this time 10 from 15. The patient continued to deteriorate with oxygen being used and her GCS was 7 at 3:45am. IV access had been obtained at 2:20am and a [full blood count] and [urea and electrolytes] sent urgently to the laboratory at around 3:30am."
Dr F recorded in Miss A's notes that the blood tests had been ordered but he did not see the results. He stated that he would have expected to receive the blood test results between 4:00am and 4:30am. Ms H does not recall the blood test results coming to ED. Intravenous access was obtained, but Miss A was not happy about having the IV luer placed into her hand. Registered Nurse Mrs I helped to hold Miss A's arm still so this could happen.
Hospital and Health Services advised me that the blood sample was collected from Miss A at 3:30am, and that the sample was received and registered on the computer system at 4:19am. The specimens were then analysed and the results were released into the computer system where they were available to clinical staff at 4:33am, the hospital computer system being the principal means by which clinical information is communicated. Laboratory policy requires unusual test results to be notified to clinical staff by telephone; this includes white cell counts of less than 3.0 109/L or greater that 30.0 109/L. Miss A's white cell count was 18.9 109/L so there was no requirement to telephone it through. The blood test results were first accessed at 4:51am by a terminal that had been logged onto by Mrs I, but Hospital and Health Services pointed out that it was not necessarily Mrs I who had used the terminal to access the results. The results were next accessed at 7:18pm that day.
Dr F decided that an urgent CT scan of Miss A's head was necessary in order to confirm his provisional diagnosis of a head injury. He explained that this was the first CT scan he had ordered at the public hospital and that he was not sure how to go about doing so. He asked nursing staff for assistance and was told to telephone the radiologist, Dr M, which he did at 3:05am. Dr M agreed to come to the hospital to perform the scan. At this point, Miss A's GCS score was 10/15. There is a printout in Miss A's ED record of electronic monitoring of her heart rate, blood pressure, and oxygen saturation between 3:00am and 4:20am.
Ms H stated that there were subtle changes in Miss A's level of consciousness as her GCS score deteriorated. After a while Miss A would respond to her mother but not to Ms H. When Ms H told Dr F that she was becoming concerned about Miss A's condition, Dr F replied that he had ordered a CT scan. Ms H then moved Miss A into the Resuscitation Room, as it was more private and easier to monitor her in there.
Dr F stated that he did not know if there was an official procedure or policy for requesting assistance from a senior doctor. He explained that nurses undertook a triage examination when patients arrived, and the nurse would then call for a senior doctor if the patient's condition was serious or life threatening. Miss A's condition was not life threatening or serious when she arrived, so no senior medical assistance was called at that point. Dr F said that when he was working in the United Kingdom, if senior help were needed he would call the consultant. Dr F was not aware of the public hospital's procedures or policies in this regard. He explained that there were two consultants and one registrar who covered the public hospital ED, but he was not sure of the exact arrangements concerning their availability.
Hospital and Health Services advised that senior medical assistance was available to Dr F that evening. Specifically, that registrar and specialist backup was available in ED, and that both junior and senior paediatric and surgical medical staff were available on call. Senior anaesthetic staff were available on call specifically if assistance with airway management was required. The procedure to request such assistance was by a telephone call; in emergency situations this could be relayed by nursing staff.
Registered Nurse Ms G was working as the duty manager at the public hospital that night. Ms G explained that this meant she was responsible for the safety of the whole hospital, and in this role she oversaw events in ED and the Intensive Care Unit (ICU) that night.
Ms G came to ED between 3:15 and 3:30am, and was told that Ms B's daughter was in Room 1, the Resuscitation Room, as she had had a head injury earlier in the week. Ms G went in to see Miss A and was very shocked when she saw how very unwell she was. Ms G said that Miss A felt hot but her temperature had been checked and was within normal range. Ms B advised that Miss A's temperature had been 37 degrees under her arm, which indicated that her actual temperature was 38 degrees. Ms G wondered if Miss A was "playing possum" but Miss A was so unwell she would not respond to Ms G. Ms G stated that Miss A did not want to be touched, her neck was arching and she was moving around in a combative way but not purposefully. Miss A would have a session of these abnormal movements then appear to sleep again; this was an ongoing pattern. Ms G lifted Miss A's top to check for a rash on her abdomen but did not see one.
Ms G then went to talk with Dr F as she was very concerned about Miss A. Ms G stated that Dr F explained to her that he had organised a CT scan with Dr M. When asked, Dr F said he had not called in an anaesthetist, so Ms G suggested this would be a good idea, as Miss A would need intubating and ventilating in order to manage the CT scan.
Ms H stated that Miss A then obviously began to deteriorate. Her level of consciousness and her oxygen saturation level dropped further, so at 3:40am Ms H and Ms B inserted an oral (Guedel) airway (a tube to keep Miss A's throat open for breathing). Dr F was not present. He stated that an oral airway does not need to be inserted by a doctor, and that this did not compromise Miss A's condition. Miss A's GCS score was approximately 9 at this stage. Ms H said that Miss A was no longer responding to commands and was tolerating the airway, which indicated a lower level of consciousness. When Ms H told Dr F about Miss A tolerating the airway he explained that an anaesthetist had been called to sedate Miss A to enable the CT scan to be carried out. Miss A was very restless and needed to be sedated, intubated and ventilated so that she would lie still enough for the scan. Ms B said that by this time she was starting to panic about her daughter's condition.
Ms H stated that Miss A then began exhibiting decerebrate extensions (abnormal flexing and extending of the body), an indication of brain injury. Her GCS score descended to 6. Ms H said that she kept Dr F informed of the changes in Miss A's condition and she assumed Dr F would have communicated these changes to the anaesthetist. Ms H commented that Miss A was difficult to examine and there was not a lot Dr F could do once the CT had been ordered. Shortly after this a GCS score of 5, and decorticate rigidity (abnormal flexor posturing of the extremities), were noted.
Dr F stated that he telephoned the anaesthetist, Dr E, at about 3:15am and asked him to come to anaesthetise Miss A so that she would lie still for the CT scan. He explained Miss A's history of a head injury 36 hours previously and a deteriorating GCS, and said that an urgent CT was needed. Dr E initially went to the CT scanner and telephoned the ED at about 3:50am to ask where the patient was. Dr F then explained to Dr E that Miss A had to be intubated and sedated in ED before she could be transferred for the CT. Dr E went to ED and sedated and ventilated Miss A. She was then transferred to the CT suite. Dr F said that Dr E inserted an endotracheal tube into Miss A when he sedated and intubated her, and Ms B (a trainee anaesthetic technician) tied it. Ms B stated that she tied the tube at 23cm at the lips.
Ms G stated that 25-30 minutes after the telephone call to Dr E he had still not arrived in ED, so she telephoned the hospital operator who told her that Dr E was waiting for them in the CT unit. Ms G asked the operator to call Dr E and ask him to go to ED instead, but he still did not arrive. Ms G stated that she and Dr F therefore went to the CT unit where they explained to Dr E that Miss A was too unwell to be transferred before she was sedated and ventilated, and he accompanied them back to ED.
The public hospital employed Dr E as a specialist anaesthetist. Dr E advised me that he has been registered with the Medical Council of New Zealand for 29 years, and that he carries vocational registration to practise the speciality of anaesthesia and pain management. Dr E had at this time been employed by Hospital and Health Services for 14 years and was the Clinical Director of the Department of Anaesthesia. He had postgraduate qualifications in anaesthesia from the Royal College of Anaesthetists in England and the Australian and New Zealand College of Anaesthetists.
Dr E was the on-call anaesthetist that evening and was also on call for ICU. Dr E advised me that he holds no postgraduate qualifications in intensive care and is not vocationally registered as an intensivist. He described his responsibility in ICU as being primarily to assist with the care and management of airway and related problems. He is not expected to be resident in the hospital during his on-call period but is expected to be within 15 minutes' travelling time from the hospital. Once a call has been attended to it is normal practice to return home. Hospital and Health Services advised me that the responsibility of the on-call anaesthetist covering ICU at this time was the care of patients in ICU, and if surgical, medical or paediatric input was required then junior and senior medical staff were available in surgery and paediatrics to assist.
Dr E stated that he was asked by Dr F to sedate Miss A to assist with a CT scan of her head, and was given Miss A's history. Dr E went to the CT Suite and found Miss A was not there, but on inquiry found that Miss A was still in ED. He arrived there at about 4:00am.
Dr E described events as follows:
"When I first set my eyes on [Miss A], it was about 4:00am. I was struck by the marked extensor spasm of the young girl who was in decerebrate and decorticate rigidity. I assessed her GCS to be around 4-5. My main concern was that she had a significant space-occupying lesion inside her skull either in the form of a blood clot or a continuing bleed. She was unresponsive to commands and was making incoherent noises. I intubated the child and tied the endotracheal tube at a distance of 20cms from the lip margin and I took over the control of her breathing and proceeded to ventilate. The trip to the CT Suite and the subsequent positioning would have taken about 15 minutes. The CT scan of the head was done between 4:30 and 5:00am. The Radiologist who performed the CT scan reported that there was no space occupying lesion inside the skull and suggested ventilating the patient overnight in the Intensive Care Unit. Although there was no space occupying lesion, the severity and the rapidity with which the illness had progressed without any evidence of fever, infection, no prodroma, no neck stiffness and without an obvious rash, I could not exclude the possibility of a contra-coup injury as being the cause of the deterioration and I accompanied her still intubated and mechanically ventilated to the Intensive Care Unit."
Dr E, Dr F and Ms H accompanied Miss A and her parents to the CT Scan Suite. Dr F stated that the scan began at 4:00am and was completed at 4:25am when he wrote up the results in her notes. The CT scan was normal and showed no evidence of trauma. Dr F wrote in Miss A's notes that there was no fracture seen on the scan, her ventricles were of equal size, there was no midline shift and no evidence of bleeding. Miss A was to be ventilated overnight in ICU. Dr M, radiologist, countersigned the notes where Dr F had recorded this. Dr M advised me that the CT showed no evidence of intracranial head injury and no abnormality that would have accounted for Miss A's clinical state. His radiology report (dated 19 July 1999, and therefore written after Miss A's death) also noted that early encephalitis or meningitis may not show in a scan. This was not written into Miss A's notes at the time.
Dr F was surprised at the normal CT result and asked Dr E if a lumbar puncture should be performed. (As there was no head injury, Dr F considered the next option to be a possible meningitis diagnosis.) Dr F recalled Dr E's reply as "no, not at the moment". Dr F stated that he asked Dr E what would happen next and Dr E replied that he would take over and accompany Miss A to ICU, where she was to spend the night ventilated.
Miss A's stepfather, Mr C, recalled that during the CT scan the doctors noted that there was no bleeding in Miss A's brain and no obvious cause for her problems. He remembered that someone then said that there must be something else wrong, but he does not remember who that was. He also does not recall a response to this observation. Ms B recalled that after the CT scan was clear, somebody suggested that Miss A could have been suffering from an infection but no one seemed to pick up on this idea at the time.
There is an entry in Miss A's medical notes timed at 4:00am by Dr E. Dr F stated that he did not see this entry and it was written after he left the CT suite. Dr F stated that he believed Dr E would either contact the paediatrician or treat Miss A appropriately himself in ICU, and that as Miss A had now left his care Dr F returned to ED.
In his entry timed at 4:00am in Miss A's notes Dr E recorded that Miss A's GCS score was 4-6 and that she had been placed under a general anaesthetic for a CT scan. The drugs he used are recorded. He then wrote that the CT showed Miss A's head was clear and that she was for ventilation overnight in ICU. He then wrote "?head injury ?meningitis for LP [lumbar puncture] in am [morning]". Medications to be administered in ICU are then listed, with the statement: "Review in am for extubation". No antibiotics were prescribed for Miss A at this point.
Ms B was concerned that Dr E did not take appropriate action after noting that Miss A was possibly suffering from meningitis. Ms B was also concerned that Dr E only noted meningitis as a possible diagnosis in the clinical records and that a lumbar puncture could be performed in the morning; also, that Dr E did not communicate this information to anyone so that action could be taken immediately. As meningitis was seen as a possibility Ms B believes a lumbar puncture should have been performed or other appropriate action taken as soon as possible. She advised me that the public hospital staff receive regular bulletins from the Ministry of Health about infectious diseases, especially meningitis.
In response to this, Dr E commented:
"With regards to not taking appropriate action to treat possible meningitis. The meningitis as the cause of her unconsciousness was considered by me in my differential diagnosis but in the absence of any features suggestive of meningitis, (the headache was not suggestive of this), I consider it unreasonable for me to be crucified for not pursuing this diagnosis further and I consider it could be dismissed due to the absence of clinical features of meningitis.
Indication for antibiotics in a head injury is where there is compound fracture or where there is any cerebrospinal fluid leakage either through the ears or through the nostrils neither of which were present but I was certainly willing to consider meningitis as a possible cause in the morning if there was no improvement in [Miss A's] condition."
ICU staff were telephoned and warned of Miss A's imminent arrival. They were told about Miss A's history of a knock to the head, vomiting, headache, that her level of consciousness had deteriorated, that Dr E had sedated and intubated her, and that the CT scan had detected nothing abnormal. They were told Miss A was to be ventilated, then woken and weaned in the morning.
Dr E stated that they arrived in ICU a little after 5:00am. He settled Miss A on the ventilator and instructed the nurse caring for Miss A about controlling her blood pressure, the maintenance of ventilator settings, and drugs needed to maintain muscle paralysis and sedation. On arrival Miss A was hypertensive (blood pressure 180/110) and her pulse was 120. She was given morphine and labetalol (to lower her blood pressure), then sedated with morphine, midazolam (a hypno-sedative) and pancuronium (a muscle relaxant) by Dr E. He also inserted another intravenous line for ready access for drug administration.
Dr E stated that his plan was to maintain artificial ventilation until the morning to achieve a low end-expiratory carbon dioxide level, and to maintain a mean arterial pressure of around 80mms mercury with fluid restrictions. Dr E stated that Miss A was now well settled and the ventilator settings were satisfactory. Her blood pressure was around 140 to 150 systolic and the oxygen saturation 99 to 100%. As Miss A was well settled, and after he had ascertained that the nurse was comfortable with his instructions, Dr E returned home, about five minutes away from the hospital.
Registered Nurse Mr J was Miss A's primary ICU nurse and was working a night shift in ICU on 16/17 July. Mr J had been working in ICU for about four months. He stated that Miss A arrived between 4:30am and 5:30am with Dr E, her parents and nursing staff. She was ventilated and sedated. Mr J said that the diagnosis was not clear to him, although he knew Miss A had had a bump on the head two days earlier, a severe headache, a deteriorating GCS and that the CT scan had detected nothing abnormal. Mr J was told that Miss A was to be sedated overnight and was for "wake and wean" in the morning. This meant that she would be weaned off the sedation and slowly woken up. Mr J stated that the fact that Miss A was for "wake and wean" indicated to him that she was not seriously unwell.
Mr J stated that on arrival in ICU Miss A had one peripheral line in her arm, and the patches on her chest were connected to monitors. A non-invasive blood pressure cuff (NIBP) was attached and it soon became obvious that Miss A had a very high blood pressure. Her heart rate was tachycardic (abnormally fast) with some ectopic (abnormal) beats, which Mr J stated is a sign of concern in a 14-year-old. Miss A's arms and legs were twitching and her pupils were 3 to 4mms in size and reacted only sluggishly to light. Mr J stated that he expressed his concern about Miss A's high blood pressure to Dr E, who gave Miss A an anti-hypertensive drug and more sedating and paralysing drugs.
Ms K was another registered nurse working in ICU that night. Ms K stated that Miss A arrived between 4:30 and 4:40am and she helped transfer Miss A from the ED bed to the ICU bed. Ms K noted that Miss A did not respond to being moved, and inquired about her sedation. Ms K was told that Miss A had been given no sedation since being intubated.
Ms K noted Miss A's pupils were size 4 and reacting sluggishly. Ms K then connected Miss A to ECG monitor leads and printed out one or two rhythm strips. (These printouts were not included with the medical file provided by Hospital and Health Services.) She stated that Miss A's heart rhythm was sinus tachycardia (a normal beat but a fast rate), with ventricular ectopics (every third or fourth beat was abnormal). Ms K then became concerned, as it is unusual for a previously fit and well young person to have a heart rhythm like this in the absence of any underlying congenital heart condition. The NIBP showed Miss A had a very high blood pressure. Mr J had connected Miss A to the ventilator. The oxygen saturation probe on Miss A's finger showed a saturation level of 100%.
Ms K stated that she brought the CTG (cardiotocograph) trolley to Miss A's bed, as she wanted a 12 lead ECG to obtain baseline data of Miss A's heart rhythm given that it had been abnormal. Dr E asked her to explain what she was doing. Ms K explained, and Dr E replied that Miss A's heart was now in a normal rhythm and this would not be necessary. Ms K then requested arterial and central lines be inserted into Miss A and she brought the necessary equipment trolleys to the bedside. Ms K explained that an arterial line gives a continuous and accurate blood pressure reading and also acts as a port for drawing blood. The NIBP, however, can be read only every minute. Ms K also explained that Miss A had only one peripheral line in her left arm on arrival. She thought that a central line would have been preferable as it gives a wider access to a blood vessel for giving fluids or drugs.
Ms K stated that Dr E declined to insert these extra lines, stating that Miss A was to be ventilated for a short time only, and weaned and woken in the morning. Ms K commented that Ms B was present, saw her bring the equipment trolleys to Miss A's bed, and witnessed Dr E's decision not to insert the extra lines. Ms K stated that she would have been happier had these matters been initiated, but in her opinion this would not have made any clinical difference to Miss A's condition. At about 5:00am Ms K left Miss A's bedside as she had to attend to another patient.
Ms B stated that the results of blood tests that had been ordered by Dr F in ED were pinned up next to Miss A's bed in ICU. Ms B is concerned that no notice was taken of these results, as they indicated that Miss A had an infection. (A high white cell count, high band and segmented neutrophils, low lymphocytes and a high erythrocyte sedimentation rate - all laboratory indicators of bacterial infection.) Mr C also recalls seeing these results. He stated that a nurse, possibly Mr J, wrote them up on a whiteboard beside Miss A's bed, within 10 to 20 minutes of their arrival in ICU. This was before Dr E left. Hospital and Health Services advised that these results were first available on the computer system at 4:33am, and were first accessed at 4:51am from a terminal that had been logged onto by Mrs I. By this stage Mrs I was working in ICU.
Dr E advised me that he did not order these blood tests, had no way of knowing that they had been ordered, and that neither the person who ordered the investigation nor the person who took down the results passed that information on to him. ICU nursing staff, Mr J and Ms K, did not recall seeing these results either.
Ms B was also concerned that Dr E did not take appropriate action in response to signs that Miss A might have been suffering from a viral infection rather than a head injury; namely, a normal CT scan, a high temperature and the blood test results. Dr E responded that:
" ... [Miss A] had no features suggestive of any infection either viral or bacterial. She had no fever; she was certainly not hot to touch. She had no neck rigidity or neck stiffness and she had no evidence of any rash on her body, however, she did have her belly-button pierced and there was a silver sleeper with a blue stone in it."
Mr J stated that he was not aware of when Dr E left ICU. Contrary to Dr E's assertions, Mr J stated that Dr E did not check with him whether or not everything was okay, or whether Mr J had understood his instructions; Dr E did not leave any parameters or guidelines for Miss A's ongoing care before he left. There were no care parameters listed by Dr E in Miss A's medical notes either, apart from a telephone call recorded by Mr J in which Dr E had said to keep Miss A's mean arterial pressure at 80. Mr J advised me that most doctors would check that all was well and understood by nursing staff before leaving ICU. Ms K confirmed that there had been no communication from Dr E to nursing staff before he left ICU.
Ms B stated that Dr E explained to her that Miss A was fine, he would ventilate her for the night and wake her up in the morning. Ms B is certain that Dr E told her Miss A was fine, and that he did not say anything else to her about Miss A's condition. Dr E, however, stated that he communicated with Ms B on several occasions. He advised me that he was concerned for Miss A, and relieved the CT had been clear. Before leaving ICU he told Ms B that he would wake Miss A up in the morning and see how things progressed. Dr E looked at the ventilator settings and talked with Mr J. Mr C said that he was not continuously present at this point, and was not aware whether there was any communication from Dr E to Ms B before Dr E left.
Mr C said that Dr E did not discuss anything with him before leaving ICU. Mr C was not aware of any discussions that Dr E may have had with Ms B, as he was in and out of Miss A's room. The only interaction that Mr C had with Dr E was when Dr E put his hand on Mr C's shoulder the first time that Miss A went into cardiac arrest.
Ms B said that she felt safe at this stage as Miss A looked stable and there was no head injury. Her husband suggested they go home and return in the morning but Ms B wanted to stay with her daughter in case Miss A woke and wanted her in the night. Ms B said she left the room to go to the toilet, and when she returned Dr E had gone and the alarms on machines monitoring Miss A's condition were ringing.
Mr J stated that shortly after Dr E left he became concerned as Miss A's blood pressure was very high, her pulse was high, and her pupils were barely reacting to light. Another nurse checked Miss A's pupils as well and Mr J discussed the situation with other nursing staff. He then telephoned Dr E and expressed his concern about Miss A's condition. Over the phone Dr E told Mr J to give Miss A 5mg of morphine, then 10-20mg of labetalol if the morphine was not effective. Mr J gave Miss A 5mg of morphine, then 5 minutes later 10mg of labetelol. Mr J said that he did not ask Dr E to come back to ICU during this conversation, although he was hoping that Dr E might offer to return. Dr E stated that Miss A's deterioration was not communicated to him until the second telephone call, at which time he returned immediately to ICU.
Mr J said that within 10 or 20 minutes, at about 5:30am, Miss A's blood pressure became labile (extreme highs and lows), and her pupils were virtually non-reactive and appeared to be enlarging slightly. Ms K returned to Miss A at this time. Ms K advised Mr J to call Dr E back to ICU. Mr J telephoned Dr E again, explained that he was very concerned as Miss A was very sick, and asked Dr E to return to ICU. Dr E returned within 10 minutes of this request.
Dr E stated that within ten minutes of arriving at his home he was telephoned by the ICU nurse looking after Miss A to say that her blood pressure had risen and that she was bucking on the ventilator. Dr E explained events as follows:
"It suggested to me that perhaps the sedation was inadequate and the patient was waking up which was a good sign, however, as I had planned to artificially ventilate her until morning, it was not desirable and I instructed that she be given 5mgs of Morphine intravenously and 5mgs of Labetalol which is a drug to control the blood pressure. However, no sooner had I hung up the telephone, the Nurse telephoned me again to say that the patient was deteriorating at which time I immediately returned to the Intensive Care Unit to find that the patient was cyanotic with the endotracheal tube which was securely tied at 20cms in the Emergency Department now well down into the 28cms mark.
It was quite obvious that the tube, which was initially endotracheal [in the throat to assist breathing], had been pushed into an endobronchial [in the passage from the throat to the lung] situation and possibly was the cause of the change in the patient's condition. I immediately repositioned the tube, bought it back to an endotracheal position and ordered a chest x-ray to confirm the position of the tube. Soon after that, in spite of increase in the Oxygen concentration to 100%, the patient initially went in to a period of ventricular tachycardia and then progressed on to cardiac arrest at which time I started cardiac massage and also went on to telephone the paediatrician on call."
Ms B stated that when Dr E inserted the endotracheal into Miss A in the ED she was the one who tied and secured the tube. Ms B is certain that she tied this tube securely at 23cms at Miss A's lips, and that Dr E may have checked this measurement at the time. Dr F confirmed that Dr E inserted the endotracheal tube and that Ms B tied it. Dr E stated, however, that he tied the tube 20cms from Miss A's lip margin. Ms B and medical and nursing staff involved in Miss A's care were not aware when or how the endotracheal tube could have shifted position.
Ms G stated that about 5:15am she went to ICU to see how things were. On arriving she found that Miss A had very obviously deteriorated. She stated that the nursing staff were very worried about Miss A and expressed to her their frustration at the difficulty of obtaining medical assistance. There was no doctor present. The nurses explained to Ms G that they felt unsupported and they had rung Dr E to return. Ms G explained that there is no doctor present in ICU at night but there is always someone on call.
During the 10 minutes that Dr E took to return to ICU Ms K said that she catheterised Miss A and took a urine specimen. She also collected blood culture bottles, as she wanted to collect baseline data. Ms K then noticed Miss A's oxygen saturation level dropping and that there was white frothy liquid in her endotracheal tube. Ms K suctioned Miss A immediately and obtained a large amount of white frothy liquid that quickly dissolved into dirty brown liquid. Ms K stated that this liquid is usually a sign of pulmonary oedema (fluid in the lungs). Ms K took a sputum specimen. Miss A's oxygen saturation levels then briefly rose before dropping dramatically down to 88%.
When Dr E arrived he began to manually ventilate Miss A in order to clear the secretions from her lungs. As more liquid was noted in the endotracheal tube Miss A was suctioned again. Her oxygen saturation level rose to 99% and stayed up. Ms K stated that at this point she suggested a chest x-ray be done, as Miss A had no known chest infection. A radiographer was called. The charge nurse suggested calling the paediatrician to assist, and Dr E agreed.
Mr J recorded in the nursing notes Miss A's time in ICU under his care as follows:
"Acute admission to unit via A&E.
On arrival pt already ventilated. Transferred to ICU bed and ventilator. Accompanied by [Dr E]. Hypertensive BP = 180/110 P 120. Given morphine and labetalol by [Dr E]. BP | = 140/80. [Dr E] charted meds and fluids and left sometime after this. Pt had been given further sedation - morphine, midazolam and pancuronium, and appeared reasonably comfortable at this stage.
Shortly after this pts pulse - 160 and pupils noted to be dilating to 4 and only very sluggish reaction. BP - again. [Dr E] phoned and gave orders to give further morphine 5mg and if that did not work 10-20mg labetalol. Given the morphine as ordered and 5 mins later 10mg labetalol.
Pts condition continued to deteriorate - labile BP pupils dilated and unresponsive. Dr phoned again and agreed to come in and reassess pt. At this stage other senior staff assisted in care of pt. Pt became bradycardic at 0600 approx and suffered a cardiac arrest. Defibrillated several times before a heart rhythm was re-established. At this point the paediatrician was also present. Pt continued to be intensively provided for by a large group of staff at time of end of shift."
Paediatrician Dr L was telephoned by nursing staff to come to assist. Her home was five minutes away by car and she arrived promptly, shortly before Miss A's first cardiac arrest at 6:20am. When Dr L arrived in ICU Miss A was already intubated and ventilated, and continuous cardiac and saturation monitoring were in place. Dr E was attending to Miss A's airway and ventilating her with a bag. There were also nursing staff attending to her. She had an electrical trace on her cardiac monitor but her pulses were difficult to palpate and Dr L requested a blood pressure reading. Miss A then quickly deteriorated into cardiac arrest and Dr L began external chest compressions.
Dr L stated that between the several episodes of full cardio-respiratory resuscitation and intensive management of Miss A's condition she obtained Miss A's medical history. Dr L stated that Miss A's ED notes, the CT report, and full blood test results (including the full blood count) were all available to her. She described Miss A's condition as extremely unstable, critically ill, and stated that there were no obvious explanations for her condition. Dr L stated that after Miss A's first cardiac arrest and resuscitation she began to consider the many possible causes of Miss A's condition and ordered an empiric broad spectrum antibiotic, which was given at 6:45am. These antibiotics were given without a specific diagnosis having been made. Dr L stated that after taking time to consider the situation her clinical impression was that Miss A's diagnosis was not known. However, the most likely explanation would be overwhelming Neisseria meningitidis septicaemia, including a significant myocarditis (inflammation of the muscular walls of the heart) and possible meningitis (a serious infectious disease, with inflammation of the brain and spinal cord membranes, or blood poisoning). Two purpura (purplish-brown skin spots which indicate haemorrhage into the tissues) were noticed on Miss A's left leg, leading to a diagnosis of acute septicaemia (blood poisoning). Antibiotics were commenced and blood cultures and throat swabs were taken.
Mr J said that after Dr L arrived he had more of a support role rather than being Miss A's primary nurse, and that Miss A's care turned into a team effort. Mr J wrote up Miss A's clinical notes at about 8:45am and left between 9:00-9:30am. No contemporaneous record of Miss A's care was kept as staff were very busy. Mr J has no recollection of the blood test results that had been ordered in ED, and is not aware of these results having arrived in ICU.
In spite of numerous aggressive resuscitation attempts, including treatment with adrenaline and defibrillation, Miss A's condition did not improve. Many medical and nursing staff were involved with Miss A's care and resuscitation. Resuscitative attempts were terminated at around 10:00am after discussion with her family, and Miss A died shortly before 11:00am. A paediatric intensive care specialist from a hospital in a city was coming to the town by helicopter to help with her care, but Miss A died before he arrived.
An autopsy was carried out on 17 July 1999. The autopsy report dated 3 August 1999 recorded that Miss A had been pronounced critically unstable and required multiple resuscitations, but was unconscious and unresponsive throughout. The report stated that CPR was initiated on eight occasions between 6:00am and 10:50am, and death was pronounced at 10:55am. The pathologist concluded that Miss A's death was due to extensive acute meningitis due to Neisseria meningitidis. The Neisseria meningitidis was identified by DNA amplification.
Registered Nurse Mrs I was working as a casual nurse on the night Miss A was in hospital. She began her shift in ED and was present when Miss A was admitted, then later shifted to ICU and was present while Miss A was being resuscitated. Mrs I happened to be working in the Ear, Nose and Throat (ENT) Department at the public hospital in November or December 1999 when she saw in the "to be filed" pile Miss A's outpatient notes from 16 July 1999. Mrs I was aware of Miss A's death and she sent her records to the Medical Records Department to be filed with Miss A's notes. When Mrs I was reading Miss A's medical file to prepare for her interview during this investigation she noticed that the ENT notes were not in Miss A's file and notified the Chief Medical Advisor's administration assistant who collected the ENT notes from Medical Records to complete Miss A's file.
As well as internal reviews and discussions about Miss A's care, and meetings with her family, Hospital and Health Services commissioned an independent Quality Assurance Review of the circumstances surrounding Miss A's death. Dr O, a specialist in anaesthesia and intensive care medicine, carried out this review on 19 August 1999. Dr O stated that the purpose was a review of case management and a comment on hospital process, with a view to making some recommendations to assist the quality assurance process. The inquiry did not seek to apportion blame. Dr O reviewed Miss A's medical records, analysed the disease process, and interviewed some of the medical and nursing staff who had been involved in Miss A's care.
Interviews were held with Ms B and Mr C, medical and nursing heads of the ED, the nursing head of ICU, Ms G, Ms K, Dr L, the Acting Head of Department of Anaesthesia and Dr E. Ms H, Mr J and Dr F were said to be unavailable for interview. However, Mr J advised me that he was available but not called to interview, and Ms H stated that she was not even aware the review was taking place. Dr F was said to be unavailable as he had moved to another country. However, he advised me that he had not left New Zealand and that Hospital and Health Services had his forwarding address.
The review made eight recommendations, as follows:
1. To counteract delays in ED, consideration to be given to developing joint medical and nursing protocols for triage and rapid referral of concerning cases to senior staff.
2. ED senior staff have training visits to other hospitals to observe triage, communication line and referral protocols.
3. A transparent protocol be developed to permit the prompt referral of critically ill patients to appropriate senior specialist staff.
4. Further development at the ICU, with an emphasis on improving staffing levels and expertise.
5. Dr E undertake a professional standards maintenance programme.
6 & 7. Critical incident debriefing be implemented to assist staff to deal with distressing incidents like this one, with consideration given to appointing a clinical psychologist.
8. A copy of the report to be sent to Miss A's family.
Hospital and Health Services responded to the report and the recommendations as follows:
1. Triage score was appropriate and Miss A was seen within 40 minutes, which is an acceptable time. However, she was not referred to senior staff upon deterioration, which was not in accordance with protocols. Protocols were all reviewed and a universal protocol developed for ambulance arrivals.
2. There was already regular contact between senior ED staff and other hospitals, which would be developed. Triage communication and referral protocols were already in place.
3. Protocol reviewed and re-emphasised to staff.
4. New ICU director appointed who had updated procedures and protocols.
5. All anaesthetic staff working in ICU to be encouraged to spend time in the city ICU as part of maintaining professional standards.
6 & 7. Critical incident debriefing being developed.
8. Report sent to family.
Ms B was not happy with this outcome, as she believed the scope of the inquiry was inadequate, not all staff involved in Miss A's care were interviewed, and no corrective action was instituted as a result.
Dr D, Chief Medical Advisor at Hospital and Health Services, responded to her concerns as follows:
" ... I do not agree that the external review carried out was inadequate:
Because [Hospital and Health Services] is a 24 hour, seven day a week organisation it is often impossible to get all staff together on one particular occasion, in this case the visit of [Dr O]. However, the nursing staff was certainly talked to in detail by the Clinical Director and the Charge Nurse for comments and input into their Quality Improvement meetings. The Clinical Director and Charge Nurse used this information with their discussions with [Dr O]. The review made eight recommendations and I would like to refer to attachment number IV which shows that all the recommendations were either actioned or were proven not to be either factually correct or relevant.
Many meetings took place to review the tragic death of [Miss A]:
09.8.99
[Dr D] with [Ms B]
16.8.99
[Dr D], [Dr E] (Anaesthetist), [Dr F] (ED Senior House Officer) and [Dr L] (Paediatrician)
17.8.99
[Dr D] with [Ms B]
18.8.99
[Dr D] and [ ... ], Clinical Director, ICU
19.8.99
[Dr O] (external review)
01.9.99
[Dr D], [ ... ] (ED Clinical Director), [Dr L] and [Dr E].
Morbidity and Mortality meetings took place in the Emergency Department, Anaesthetics Department and Paediatric Department and also combined Emergency, Anaesthetic and Paediatric Department meetings. Policies in the Emergency Department and ICU have been reviewed as a result.
... "