Names have been removed (except MCDHB/Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

 

Te Whatu Ora|Health New Zealand
Te Pae Hauora o Ruahine o Tararua MidCentral

Emergency Medicine Specialist, Dr B

 

A Report by the Deputy Health and Disability Commissioner

 

Contents

Executive summary
Complaint and investigation
Information gathered during investigation
Opinion: Dr B — adverse comment
Opinion: MidCentral District Health Board — breach
Changes made since events
Recommendations
Follow-up actions
Appendix A: Accelerated Chest Pain Pathway

 

 

Executive summary

1. This report discusses the care provided to a woman in her fifties when she presented to the Emergency Department (ED) at a public hospital with a history of chest pain. Following assessment, the woman was discharged from ED five hours later, without having been considered for admission. Later that day, she suffered a cardiac arrest at home and died.
2. This case highlights the importance of clear and unambiguous communication between clinicians, as well as the critical importance of documentation of any such communication.

Findings

3. The Deputy Commissioner found that MidCentral District Health Board breached Right 4(1) of the Code for failing to provide services of an appropriate standard. Contributing factors to this breach were several instances of poor documentation by a number of MCDHB staff who were involved in the woman’s care, and practices in place at MCDHB at the time that resulted in the woman receiving less assessment and fewer clinical investigations than appropriate based on her clinical results. The Deputy Commissioner considered that MCDHB’s system allowed for clinical decisions to be made with too much weight given to resourcing capacity considerations, and not enough to the clinical needs of patients.
4. The Deputy Commissioner also made adverse comment about the emergency medicine specialist who had responsibility for the woman’s care while in the ED. While the ED specialist had identified that the woman should have been considered for admission, he did not take sufficient steps to ensure that this happened before the woman was discharged. The ED specialist’s documentation of the woman’s care and related discussions was also not to the expected standard. Overall, however, the Deputy Commissioner found that his care did not amount to a breach of the Code.

Recommendations

5. It was recommended that Te Whatu Ora consider utilising this case for staff training on the importance of adequate documentation, communication, and completing specialist referrals. In addition, the Deputy Commissioner asked that Te Whatu Ora and the ED specialist provide a joint written apology addressed to the family for the issues identified in this report. As a number of other appropriate actions have already been taken by Te Whatu Ora and the ED specialist since these events, the Deputy Commissioner considered that no further recommendations were required.

 

Complaint and investigation

6. The Health and Disability Commissioner (HDC) received a referral from the Coroner concerning the services provided to Mrs A by Te Whatu Ora|Health New Zealand Te Pae Hauora o Ruahine o Tararua MidCentral, formerly known as MidCentral District Health Board (MCDHB).[1] The following issues were identified for investigation:

• Whether MidCentral District Health Board provided Mrs A with an appropriate standard of care in 2018.
• Whether Dr B provided Mrs A with an appropriate standard of care in 2018.

7. This report is the opinion of Deputy Commissioner Deborah James, and is made in accordance with the power delegated to her by the Commissioner.
8. The parties directly involved in the investigation were:

Mr A                                                                      Consumer’s husband
Dr B                                                                       Emergency medicine specialist
Ms C                                                                      Consumer’s daughter
MCDHB                                                                Provider
 

9. Further information was received from trainee intern (TI) Mr D,[2] Dr E, the ambulance service, and the Coroner’s Office.
10. Also mentioned in this report:

RN F                                                                      Registered nurse  
Dr G                                                                       Cardiology registrar
Dr H                                                                       ED doctor
Dr I                                                                        Emergency medicine specialist
Dr J                                                                        Cardiologist

 

Information gathered during investigation

11. Mrs A (in her fifties at the time) presented at the Emergency Department (ED) at the public hospital with a two-day history of transient but severe chest pain. Following two electrocardiograms (ECGs) and two rounds of high sensitivity serial troponin testing to investigate any serious underlying health issue, Mrs A was discharged from ED after five hours. Later that evening, Mrs A suffered a cardiac arrest at her home and died. I extend my sincere condolences to her family.
12. Mrs A’s husband and daughter, Mr A and Ms C, stated that “a sequence of unfortunate events led to this death that [they] feel could have been avoided had sufficient due diligence been carried out”.
13. Key issues in this case include the importance of clear and unambiguous communication between clinicians and the critical importance of documentation of any such communication that may affect clinical decision-making, as well as documentation of medications given. If such communication and record-keeping is inadequate, misunderstandings between clinicians can arise, and in turn place patients at risk of poor clinical decision-making and inadequate follow-up care.
14. I acknowledge the initial inquiry carried out by the Coroner into the circumstances surrounding Mrs A’s care. Information from the Coroner’s inquiry provided to HDC has been of assistance in my investigation.

Background

15. Mrs A experienced chest pain while at home. She had also experienced an episode of chest pain the previous evening. At 5.12am an ambulance was called to attend, and by 5.36am ambulance staff were on site and assessing Mrs A.
16. The ambulance care summary (ACS) noted that Mrs A had no history of a heart condition, but that three of her siblings had suffered a heart attack in their mid-fifties. The ACS also noted that Mrs A was on medication[3] for managing dyslipidaemia (high cholesterol).
17. Mrs A was transferred to the public hospital for follow-up care. On the way to the hospital, Mrs A reported that her pain had resolved and she was feeling better.

Initial care in ED

18. Mrs A arrived at the ED at 7.03am and was assessed by a triage nurse, who noted: “Chest pain & [left] arm pain/weakness — all night & worse on movement … Currently pain free.” The triage note stated that the pain had begun at 6pm the previous day. At 7.30am a further nursing assessment was completed. At this time it was also noted that at 5am that morning Mrs A had experienced shortness of breath along with chest pain and left arm heaviness. Observations taken showed Mrs A to be haemodynamically[4] stable, with a pulse of 64 beats per minute (bpm) and blood pressure of 133/108mmHg. An ECG showed no acute ischaemic[5] A blood specimen was sent to the laboratory for analysis, including a check of the troponin-T[6] level.
19. Dr B (an emergency medicine specialist) was the ED consultant on duty. His shift had commenced at 7am. Dr B told HDC that normally the ED should have a complement of nine advanced trainees, but at that time there was only one junior registrar and one medical officer of specialist scale (MOSS),[7] and the ED was much busier than usual. MCDHB told HDC that at the time of Mrs A’s presentation to the ED (7.17am), there were seven nurses on duty, three senior house officers (SHOs), and two senior medical officers (SMOs), and at the time she was discharged five hours later, there were 10 nurses, five SHOs, three SMOs, and one MOSS on duty. MCDHB said that this was indicative of a normal shift pattern.
20. During Mrs A’s presentation, 54 patients were registered in the ED, with seven in the ED observation area at the time she was discharged. MCDHB told HDC that while the ED was initially in “Green” status, meaning that capacity matched demand, the shift quickly became busy, and at 10.45am the ED escalated to “Yellow” status, which remained through to the time of Mrs A’s discharge.
21. Dr B described Mrs A’s initial ECG as “unremarkable”, and allocated a final-year medical student, TI Mr D, to examine Mrs A. This occurred sometime between 7.30am and 8.39am (after the nursing assessment and taking of bloods, but before the blood results were reported[8]). At 9.51am, Mr D noted the history obtained as follows:[9]

“Yesterday afternoon was walking home distance of 1–2km which is further than normal daily walk. Onset of 8/10 central CP [chest pain], no radiation … Relieved with rest. Slept that evening and woke for night shift — awoke with similar character of pain but more mild. Pain waxed/waned and has now completely resolved. Never experienced CP like this before.”

22. Mr D noted Mrs A’s risk factors as a history of smoking, high cholesterol, and a family history of cardiovascular disease. Mr D noted that on examination, Mrs A had an irregular heart rate and a heart murmur.[10]
23. Mr D told HDC that following his examination, he discussed his findings with Dr B, who accompanied him to confirm the findings and discuss a plan with Mrs A and her family.
24. Dr B confirmed that Mr D discussed his findings and impressions with him, after which he attended Mrs A himself and conducted his own complete examination. Dr B recalled: “I have a specific memory of being very impressed that this Trainee Intern had detected a new heart murmur, which I then confirmed during my own examination.”
25. Mr D told HDC that following this examination, “[t]he provisional plan was for bloods to check the troponin level and a referral to cardiology to investigate the aortic murmur on an outpatient basis”. Mr D stated that his response to HDC was based on his medical notes of Mrs A’s care. The “provisional plan” referred to here is the same as that reproduced at paragraph 61 of this report. The plan was entered into the medical notes at 10.18am. However, based on some details in the note,[11] and the time at which it was recorded (nearly 30 minutes after the initial examination notes[12]), it is not clear at what precise point in Mrs A’s care the provisional plan was formulated.
26. Initially, Mrs A’s care followed the Accelerated Chest Pain Pathway[13] (ACPP — see Appendix A). This pathway is a guide for clinicians in treating patients who present with chest pain. Several steps on the pathway indicate when a patient’s care should continue to follow the pathway, and when the pathway should be exited, including when certain “red flags” are present. One of the red flags that should prompt clinicians to exit the pathway is if the patient has a “positive hsTnT [high sensitivity, troponin T] (not known to be chronically raised)”. A positive hsTnT is defined on the ACPP as being more than 14 ng/L.[14] An hsTnT level of 14 or greater is sensitive in detecting cardiac damage, but it is not specific and there may be other causes for an elevated troponin level. In the case of a patient with a non-chronic positive hsTnT, the ACPP prompts clinicians to refer the patient to Internal Medicine. Mrs A’s initial troponin result was 22ng/L and the subsequent actions taken are noted from paragraph 44 of the report.
27. Dr B told HDC that based on Mrs A’s history and the finding of a heart murmur, he wanted her to be seen as an inpatient by the Cardiology service, and believed she required an echocardiogram. Dr B said that the ACPP did not capture Mrs A’s presentation properly, which he said suggested a more serious condition, and for that reason the ACPP was exited at that stage.
28. The Critical Incident Review of this event (discussed later in this report) also concluded that Mrs A required admission “even before she had a troponin result”.
29. Dr B stated that around the time of his examination, he saw a Cardiology consultant, Dr E, and a Cardiology registrar, Dr G, as they were reviewing another patient in the ED at that time. Dr B said that he took the opportunity to speak with Dr E and his team about Mrs A, with a view to asking them to review Mrs A and admit her to the Cardiology service.
30. Unfortunately, there is no contemporaneous record of this discussion, or any further potential discussions, between ED and Cardiology staff concerning Mrs A’s care. This aspect of her care is discussed further below. In the event, Mrs A did not receive a review by Cardiology for the purpose of determining whether she should be admitted as an inpatient during this episode of care.

Initial discussion with Cardiology

31. In relation to how a referral to Internal Medicine would typically be made or communicated, Dr B told the Coroner:

“Patients with chest pain are typically referred [to Internal Medicine departments] via page, text page, handed a sticker or asked to review at the bedside from any member of the ED team to the registrar or consultant on cardiology.”

32. Dr B also told HDC that at that time, the process for making a day-shift inpatient referral to Cardiology was to telephone the team, describe the patient, and request a review.
33. Dr B further stated:

“[I]t would be routine for the ED to ask ‘would you please see this patient with X chief complaint?’ A name, room assignment and NHI would be exchanged but no further data available for the review to be completed.”

34. Dr E told HDC that a consultation request between services needs an oral or written request for a consultation and “question(s) to be answered or discussed; an[y] oral or written information about the patient and results of initial workup and initial testing”.

Dr B’s version of events

35. Dr B told HDC that at the time, it was not his usual practice to document calls to an admitting service asking them to review a patient. In this case, the occurrence, content or outcome of any discussions between ED and Cardiology staff in relation to Mrs A’s care are not documented by Dr B or any other MCDHB staff.
36. Dr B said that he approached Dr E, told him Mrs A’s name, described her presentation and his examination findings (including the previously unreported heart murmur), and asked if Cardiology would review Mrs A while they were in the ED. Dr B said that Dr E then asked him if there were any blood results available, and he replied that there were not.
37. Dr B told HDC:

“I have a clear memory of [Dr E] and his team then speaking amongst themselves in order to triage their patient load that day and, as a group, deciding not to see [Mrs A] at that time because of the lack of blood results.”

38. Dr B said that he was not surprised by this decision, as in his experience it was a relatively common occurrence for review requests to Cardiology to be declined, and he was aware that Cardiology was operating under significant resource constraints at the time.
39. In a response for the Coroner, Dr B said:

“Cardiology did not review at the time of my request, instead recommending waiting for a standard emergency department evaluation using the accelerated chest pain pathway [ACPP], which includes serial ECG and troponin testing.”

Dr E’s and Cardiology’s version of events

40. Dr E recalled that he was in ED with Dr G to see a patient referred to him at the morning handover meeting. He said that Dr B told them that he had a patient who “might be for [Cardiology]”, and mentioned her history, ECG result, current pain-free condition, and that she had a heart murmur and was awaiting blood results. Dr E stated that he did not go to see Mrs A because it was not clear whether a consultation from the Cardiology service would be needed because the result of the first troponin measurement for Mrs A was not yet known. Dr E said: “I decided to wait for a consultation request, in the case a cardiac consult turned out to be needed once the blood results were available.”
41. Dr E told HDC that his conversation with Dr B would have occurred sometime between 8.15–8.30am; Dr G told HDC that the approximate time of this discussion was around 8.30–9am, “immediately after the morning medical handover meeting which starts at 0800hrs and is usually complete by 0830hrs”. Dr E submitted that this was the only time that he had a discussion with Dr B or anyone in the ED about Mrs A that day.
42. Dr E and Dr G wrote a retrospective note about this discussion with Dr B, after learning of Mrs A’s death. The note was written by Dr G, and edited five days later. The note records:

“During a discussion with [Dr B] he told us that a patient that came to the ED earlier that morning and pointed towards the patient saying ‘can you look at this patient, she might have something for you, or she might be coming your way.’ At that time he was awaiting blood results for this patient. There was no tentative diagnosis, nor any question to be answered (we did not get given a clear referral and did not get handed over any patient details.)

After seeing the two patients presented to us during the morning report [Dr E] and I discussed how we should handle this request from [Dr B]. Neither of us felt as [if] this was a request for a consultation and felt that if the patient in question turned out to be a cardiac patient we, or the colleague on call for the internal medicine department in case of NSTEMI, would receive a request to come and see the patient. This was because the patient was presented as ‘might be something for you’. The work up in the ED was obviously not finished at that time. [Mrs A] did not have laboratory results ready and there was no tentative diagnosis nor question for the consultation. We left the ED to continue on with our inpatients and were awaiting a referral.”

43. Dr E acknowledged that he should have documented his conversation with Dr B in the clinical notes at the time, as would have been his usual practice, but said that looking back, the circumstances were “not normal and at that time [he] did not think of doing that”. Dr E told HDC:

“When I learned from [Dr B], 3 weeks after the death of [Mrs A], that she had positive troponins and an episode of a chest pain in the ED before her discharge home, I realised that there was an issue.”

Subsequent care and troponin-T results

44. Mrs A’s blood results were reported at 8.39am, and showed a troponin (hsTnT) level of 22ng/L. A normal range for hsTnT is 0–13ng/L. The following note is visible underneath the result:

“In the appropriate clinical setting, raised hs-Troponin T may indicate myocardial infarction, but there are multiple other causes of raised levels which may need to be considered.”

45. Dr B told HDC:

“After the first Troponin-T result of [22] became available, I asked the Trainee Intern to relay this information to the Cardiology Service and ask again for them to review [Mrs A].”

46. Dr B submitted that this was the second time he sought a review of Mrs A from Cardiology that day.
47. Mr D told HDC: “As a TI it would not have been normal practice for me to discuss matters related to further patient management or disposition[15] with other specialists.” Mr D recalled discussing Mrs A with Cardiology on only one occasion during her hospital stay, and that this was not in relation to troponin results or seeking an inpatient review (see paragraph 65).
48. In response to Mr D’s comments, Dr B told HDC:

“In my view it is unremarkable for a trainee intern to be asked to communicate a review request to another service, together with conveying basic clinical information such as the troponin test results and the history and symptoms agreed upon when I assessed [Mrs A] together with [TI] [Mr D] that day.”

49. There is no documentation of what was discussed between Dr B and Mr D concerning the initial blood results and agreed follow-up actions, nor any clinical record of any further discussions between ED and Cardiology staff concerning Mrs A’s care.
50. Dr B’s recollection of events is that when Mr D got back to him about Cardiology’s decision on the above points, he understood that Cardiology had declined the review at that time and asked for a repeat Troponin-T test.
51. Dr B told HDC that he then would have asked Mr D to repeat the troponin-T test and, if it remained elevated, to relay the result to the Cardiology service again with a request to review Mrs A.
52. In Mr D’s response to HDC about his role in Mrs A’s care, there is no mention of him being asked by Dr B to relay the troponin result to Cardiology and ask for a review of Mrs A, or that he told Dr B that Cardiology had declined to review her following the initial troponin result.
53. The repeat blood specimen for troponin-T testing was sent to the laboratory for analysis at 9.50am, and the results became available at 10.32am. There is no information on the bloods form or elsewhere in the clinical records to confirm which individual clinician requested the repeat troponin.[16] This further blood testing coincided with a recurrence of Mrs A’s chest pain around 9.50am, the circumstances of which are detailed further below.
54. At 10am, RN F documented in the nursing notes that she administered Mrs A “2 puffs” of GTN[17] spray due to a recurrence of central chest pain. The full nursing note recorded at this time states: “2 puffs GTN given for central [chest pain]. ECG obtained — Obs updated. Trop T repeat sent.”
55. The rationale for the repeat troponin is unclear. Dr B’s recollection suggests that it was ordered due to his understanding that Cardiology had declined to see Mrs A following its review of the initial troponin results, and asked for the test to be repeated. However, there is no documentation outlining how the repeat troponin came to be required and requested.
56. RN F stated that she has no recollection of what care she provided to Mrs A on the day beyond what she recorded in the nursing notes. She could therefore not provide any clarification to HDC on her recollection of who ordered and sent the repeat troponin test, or the rationale for doing so.
57. RN F told HDC that GTN spray is administered in ED if the patient is experiencing central chest pain or pain that appears to be chest pain. She explained that MCDHB policy allows for GTN to be given as a one-off Standing Order, which allows a nurse to administer a medication without a specific doctor’s order.[18] RN F stated that an ECG must be obtained at the same time, which a doctor (preferably the treating doctor) must review. An ECG was taken at 9.53am, which again showed no clear ischaemic changes and was signed by Dr B at 9.59am. RN F told HDC that she would have administered the GTN prior to obtaining the ECG, followed by the documentation of those actions.
58. RN F stated that unfortunately she did not document the GTN appropriately according to the standing order protocol. She said that her normal practice would have been to give the GTN, record it on the medication chart, and “get a doctor to sign it or put under a verbal order”. In this case, the GTN was not recorded on the medication chart. RN F told HDC that because Dr B signed the second ECG (at 9.59am) it appears that the chest pain that Mrs A experienced had been escalated to him at that time.
59. In relation to Mrs A’s recurrence of chest pain, Dr B told HDC that he does not recall having been made aware of this or that Mrs A had been given two puffs of GTN for the pain.[19] MCDHB told HDC that based on the clinical notes, it does not appear that the recurrence of Mrs A’s chest pain was escalated to a doctor. Dr B said that had he known, he would have asked for that information to be passed on to Cardiology together with the second troponin T result when it became available.
60. At 10.05am, RN F documented: “Meds given as charted. Await plan post 2^nd blood result.”
61. At 10.18am, Mr D documented the following clinical plan:

“1. Bloods
2. Await repeat troponins
3. ?Cardiology outpatient referral for new murmur
4. Analgesia + acidex + omeprazole charted + given”

62. At 10.32am, Mrs A’s repeat troponin result reported a troponin-T level of 21ng/L (similar to her initial result of 22ng/L).
63. Dr B submitted that it was after this second troponin result became available that Cardiology would have been contacted again by Mr D to convey the result of the second positive troponin and asked for the third time that day to review for Mrs A. However, as noted above, this is not reflected in the clinical record.
64. Dr B recalled:

“Repeat discussion with cardiology directed us to refer [Mrs A] to outpatient clinic for follow up testing as a routine chest pain patient who had two troponins both elevated but not rising.”

65. Mr D recalled contacting Cardiology on only one occasion, and stated that he cannot recall specific details of the discussion, including whether troponin results were a part of it. He told HDC:

“I vaguely recall having a discussion with the cardiology registrar [Dr G] about how to request an outpatient echocardiogram. I do not recall the specific details of this discussion.”

66. Dr G also recalled that Mr D contacted her by telephone asking for advice on how to organise an outpatient echocardiogram for Mrs A, but does not recall the timing of that contact. Dr G said that she was not informed about the positive troponin levels, and did not offer any advice to Mr D on whether to discharge Mrs A. Dr G cannot recall having any other discussions about Mrs A other than this telephone call with Mr D, and the initial discussion in the ED.
67. There is no documentation of this discussion between Mr D and Dr G, and it is not possible to know at what time the discussion occurred, including whether it was before or after the second troponin result was known.
68. At 12.06pm, an electronic referral for an outpatient echocardiogram was completed.[20]
69. At 12.17pm that afternoon, and directly beneath the clinical plan documented by Mr D at 10.18am, Dr B documented:

“above plan was to my design
brief discussion with cardiology reg followed up by TI
agree new aortic m, suspiciou[s] for stenosis”

70. The records show that Mrs A was discharged home at 12.18pm.
71. In his initial statement to the Coroner, Dr B said that the decision to discharge Mrs A home and refer her to the outpatient clinic for follow-up testing was at the direction of Cardiology and “hinged on [MCDHB’s] accelerated chest pain pathway”. However, Dr B subsequently accepted that in this case the decision to discharge Mrs A was ultimately his responsibility as the ED consultant. Dr B told HDC that he cannot recall whether he saw Mrs A for a second time before she was discharged, but considers it was likely (in line with his usual practice), and said that he “must at the very least have undertaken a paper review”.
72. Apart from the above record documented at 12.17pm, and with the exception of nursing observations, there was no documented record of discussions, assessments or treatment plans for Mrs A’s care between 10.18am and her discharge at 12.18pm. MCDHB told HDC that the lack of documentation of discussions and medical decision-making is disappointing and is not accepted practice. MCDHB suggested that a combination of factors may have contributed to this, including “the busy-ness of [Dr B] with multiple other patients and the well-recognised insufficient number of computers on which to document medical notes”.
73. Shortly after Mrs A’s discharge, at 1.41pm, Mr D completed a referral form for Mrs A to be seen at the Cardiology outpatient clinic, with urgent priority. The referral noted the provisional diagnosis of “? aortic valve disease”, and that Mrs A had been booked for an outpatient echocardiogram.
74. That evening, Mrs A suffered a further recurrence of chest pain at her home and was attended by ambulance paramedics at 7.16pm. While being examined by ambulance staff, Mrs A had a cardiac arrest. Sadly, despite attempts to resuscitate her, Mrs A died at home.
75. A post-mortem examination found the cause of Mrs A’s death to be ischaemic heart disease[21] due to coronary artery atherosclerosis.[22]

Critical Incident Review

76. Dr H carried out a Critical Incident Review presentation to ED staff, in which Mrs A’s case was discussed, including the following questions:
    1. Should Mrs A have been on the ACPP, or another pathway?
    2. “What to make of her troponins?”
    3. Should she have been discharged?
77. MCDHB stated that after the presentation, an extended discussion was held about the appropriateness of Mrs A’s evaluation, treatment, and disposition in the ED. Dr H told HDC that according to his notes from that time, issues discussed included that both Mrs A’s troponin results were over 20, and that “Cardiology recommended discharge without seeing [the] patient”. Dr H said that ED consultants also highlighted issues with “documentation, communication (both within the [ED] service and between the ED and Cardiology) and [Mrs A’s] placement on a low-risk pathway when she was, in fact, high-risk”. Dr H stated:

“We discussed the current practice of caring for patients with chest pain at the public hospital. In our negotiations with cardiology and with internal medicine several years ago, it was reluctantly agreed that admitting every patient with chest pain who had a troponin greater than 14 would be too much of a burden for the already stressed services of cardiology and internal medicine. At the time, it was informally agreed that patients with a troponin over 20 … would be admitted to cardiology during bank hours and to internal medicine after hours. We discussed how this, too, has slipped, and often the cardiology registrar or general medicine registrar refuses to accept patients with a troponin of greater than 20 (but less than 50) … for admission and instead recommend a second troponin, with the direction to send the patient home if there is no significant rise. We all agreed that this is not part of any proven pathway and is often inappropriate, as it was in the case of [Mrs A].”

78. In relation to this, Dr H confirmed to HDC that the practice described above was “something that the medical registrars have been doing since before the inception of the ACPP [in 2016] and it is the advice given to ED junior doctors when patients are referred to them for admission”. Dr H also stated that the degree of elevation of troponin is important in determining the seriousness of a patient’s illness, and that “[t]roponins are not simply positive or negative”. He said that the practice of sending home patients with two elevated troponins less than 50 that have not changed significantly is something pushed by Cardiology and General Medicine, and that “there has been no formal consultation or agreement with emergency medicine about this practice”.
79. Dr E told HDC that he was not aware of any “informal agreements” about caring for patients with chest pain. He noted that at the time of Mrs A’s care he had been working at the hospital for a few months, and that he was not part of the discussions to which Dr H referred that occurred “several years ago”. MCDHB told HDC that the Executive Leadership Team was not aware of the informal practice described in the above excerpt from Dr H regarding the management of patients with troponin levels over 20. MCDHB said that it understood that its clinicians were following the ACPP pathways.
80. Dr B told HDC:

“[Mrs A’s] case occurred in a context of long-term diagnostic decision creep paired with under-resourced departments — cardiology and emergency medicine. I did want cardiology to review [Mrs A] and asked for that to happen.”

81. At the critical incident review with ED staff, it was agreed that Mrs A’s symptoms required that she exit the ACPP (and enter the Acute Coronary Syndrome pathway). Dr H told HDC: “We agreed that she required admission, even before she had a troponin result.”
82. The Chief Medical Officer at MCDHB at that time also told the Coroner that following the critical incident review it was concluded that Mrs A should have been physically seen by Cardiology and a written consultation undertaken while she was in ED, but with recognition that Cardiology and Dr B were both very busy on that day.

Serious Adverse Event Review

83. In October 2019, MCDHB commenced a Serious Adverse Event Review (SAER) regarding the care provided to Mrs A. As part of this, MCDHB obtained expert advice from an emergency medicine specialist, Dr I, who was the author of the SAER report, and cardiologist Dr J. MCDHB accepted their advice and recommendations.
84. Dr J stated: “On balance, I feel that not only should [Mrs A] have been assessed by the cardiology team, but that she should have been admitted to hospital for further assessment.” Dr J said that the ACPP was essentially rendered redundant for Mrs A as a result of her raised troponin and recurrent chest pain.
85. Dr J further noted:

“[Mrs A] had her cardiac arrest in the presence of paramedics but was still unable to be resuscitated. It may well have been that, even if she had been in hospital, the outcome may have been the same.”

86. Dr I identified the following key issues in the SAER:
    1. “The decision to discharge [Mrs A] from the ED [in] 2018 left her at risk of suffering a cardiac event the degree of which was difficult to ascertain. On those early results available the risk was not high.”
    2. The pathways in place at MCDHB for patients with acute chest pain would point towards recommending further observation, more investigations and consideration for admission.
    3. “Practice in cardiology and emergency medicine includes a consideration of the degree of elevation of the Troponin level in chest pain rather than simply being positive as stated in the pathway. Developments in practice may have evolved unilaterally by in patient specialists rather than been introduced with the involvement and engagement of the ED service.”
    4. The events as documented suggest the responsibility for making clinical decisions and duty of advocacy for Mrs A remained with Dr B on the day. Dr B’s reported concern and frustrations about the decision-making were not formalised or recorded at the time, and his duty of advocacy for Mrs A on that day was not maintained.
    5. The Trainee Intern was used as an intermediary in discussions with the Cardiology team once results were available and referral/disposition being planned. This does not represent an appropriate level of communication between services regarding definitive care and disposition decisions. Further engagement with the patient before discharge and more comprehensive documentation by Dr B as the supervising ED doctor would have been expected.
87. Dr I also sounded the following note of caution concerning hindsight bias:

“The seriousness of the event can produce hindsight bias by all parties.

With regard to the ED consultant this bias could lead to a feeling of concern and discomfort about the decisions made on the day which are greater than were actual at the time.

With regard to cardiology staff this could lead to defensive responses to what information was relayed to them on the day and the advice offered.

With regard to expert reviews this could lead to clear cut opinions on what should have been the outcome if the written pathways were followed on the day. The reality is that such documents are a guide rather than representing policy and require complex judgements case by case.”

88. The SAER report made several recommendations, all of which have since been implemented. The actions taken and changes made are outlined in the “Changes made since event” section of this report.

Further information

Ms C

89. Ms C stated:

“Losing my mother has devastated myself and my family and if you can make any recommendations today that could stop this happening to another girl who loves her mum then I would be forever grateful.”

MCDHB

90. In relation to Dr B’s role as ED SMO in the supervision of more junior doctors and medical student TIs, MCDHB told HDC:

“All patients seen by a [TI] belong to the ED SMO. TIs are not yet doctors and although they are allowed to interview and examine patients on their own, an ED SMO must also interview and examine the patient and document their agreement or disagreement with the findings and plan. RMOs function independently within the ED; SHOs have very close supervision and must present their cases to an ED Consultant or Registrar. ED Registrars are even more independent and are expected to make independent patient care decisions.”

91. MCDHB stated its position that while many TIs will write a note on patients, it is the ED consultant’s responsibility to complete the clinical documentation.

Dr B

92. Dr B said that his preference was for Mrs A to be admitted as an inpatient and that he attempted to arrange that with ED making three verbal contacts with Cardiology — “after initial examination, after initial blood testing, and after repeat troponin t and ECG testing were resulted”. Dr B submitted that the number of contact points with Cardiology highlighted the complexity of the decision and the need to deviate from the routine ACPP guideline. Dr B told HDC that he understood that two formal referrals had been made by Mr D on his behalf.
93. Dr B submitted the following assessment of events:

“The key issue seems to be whether or not a formal inpatient referral was accepted by the Cardiology team. As per my previous statement, I believe the ED team asked the Cardiology team to see [Mrs A] — a method of referral consistent with local practice at the time — and the Cardiology team asked for [Mrs A] to be referred as an outpatient without physically reviewing her first. There is of course an issue about whether I should have accepted that outcome. With hindsight I can see that my acceptance was likely influenced by my experience of it being common for the Cardiology team to either decline to physically review patients or, following review, decline inpatient admissions. This was a reality of resource constraint at the time.”

94. Dr B acknowledged that his documentation relating to Mrs A’s care, including discussions with the Cardiology team or any disagreement to investigate Mrs A as an outpatient, was “not optimal” and not best practice. He said that this was likely due to acute competing demands at the time.
95. Dr B told HDC:

“[I]n [Mrs A’s] case, I left the plan with the family and patient that I would get cardiology involved and when I could not get cardiology involved I should have updated them. They may not have seen communication from the TI as communication from me.

…

The responsibility for the communication outcomes rests with me. This patient may have had a better outcome if I had come to a clear expectation with my cardiology colleague that the information they felt essential to their review, ‘a troponin T test’, was there for them to chase as they reviewed the patient. I have made this a firm hand over as part of my communications since.”

96. Dr B stated that both prior to Mrs A’s care and subsequently, the ED has had elevated concerns for broader patient safety in respect of patients presenting with chest pain. Dr B said that since these events he has “put extensive effort into defining and understanding these issues and problems and how we can prevent this type of bad outcome in the future”, and carried out a significant audit to “clarify the risk we are placing patients like [Mrs A] in”.[23] Dr B stated that the purpose of the audit was to:
    1. Identify any deficits in local practice and standard of care generally in order to make improvements;
    2. Understand the “outcome and lost opportunity” in cases where two positive troponin results for a patient were obtained and the patient was not admitted; and
    3. Adjust the local practice pattern so that patients like Mrs A can get accelerated diagnostic imaging and/or Cardiology review for selective angiography or stress testing.
97. Dr B told HDC that when he excluded all the other causes of elevated HsTnT (and those with known heart disease or high HsTnT), the audit showed that of 575 presentations of patients who were not admitted and discharged following two positive troponin results during the 18-month sample period, 39 patients (about 7%) suffered a major adverse cardiac event or death within 90 days of discharge.
98. Dr B said that the results of the audit are “clinically unsettling and have started to move the pendulum for increased access to hospital beds and testing for these patients locally”. Dr B believes that this is not an isolated problem, and said that he would like to explore it nationally. He stated: “I am engaging with Massey University’s economics department and New Zealand Emergency Medicine Research Network toward these aims.”

Responses to provisional opinion

99. MCDHB and Dr B were given the opportunity to respond to the provisional report. Both accepted the findings.
100. Mr A and Ms C were given the opportunity to respond to the “Information gathered during investigation” section of the provisional report. They had no further comment.

 

Opinion: Dr B — adverse comment

Initial discussion with Cardiology in ED

101. Dr B said that because of Mrs A’s history and heart murmur, he wanted her seen as an inpatient by Cardiology and to receive an echocardiogram. He said that he asked Cardiology consultant Dr E, who was in the ED, to review Mrs A in the ED, but this request was declined because there were no blood results available at that time. Dr B said that he was not surprised by this decision because he was aware that Cardiology was operating under significant resource constraints and it was common for such requests to be declined.
102. Dr E recalled that Dr B told them that he had a patient “that might be for” Cardiology, and discussed all the relevant clinical information available at that time. Dr E told the Coroner that he did not review Mrs A because the result of the first troponin blood test was not yet known, and he “decided to wait for a consultation request” in case that was needed once the troponin result was available. In a retrospective note written by Dr E and his registrar, Dr G, they stated that Dr B pointed towards Mrs A and said, “Can you look at this patient, she might have something for you,” but also that they did not get given a clear referral or handed any patient details. Neither of them felt that the discussion with Dr B was a request for a consultation, and they thought that they would receive a request to review the patient later on if it turned out that she required that.
103. Dr B and Dr E have different views on whether their communication in the ED constituted a request for Mrs A to be reviewed by Cardiology. There may have been a miscommunication, but I consider that if a clinician believes it is in a patient’s interests that their care be handed over to another specialist service, this must be conveyed explicitly and documented. In this regard, I note Dr B’s reflection that Mrs A may have had a better outcome if he had come to a clear expectation with Dr E that Cardiology would follow up on any troponin T test deemed necessary to consider a Cardiology review.
104. There is no contemporaneous documentation on this matter to assist with understanding the content of the discussion, and both Dr B and Dr E accept that they should have documented it at the time. I accept that Dr B believed that he had requested a Cardiology review for Mrs A, but that Dr E did not consider that a referral for review had been made. The outcome of the discussion was that Cardiology was willing to consider the matter again once informed about the results of Mrs A’s first troponin test. However, as discussed further below, there is significant doubt as to whether Cardiology was informed of the subsequent troponin results, and the extent of its involvement in decisions made regarding Mrs A after the initial discussion.

Role of TI and Cardiology involvement

105. Dr B’s version of events suggests that the TI would have had a central role in Mrs A’s care as an intermediary between ED and Cardiology. Dr B said that in his view it is unremarkable for a TI to be asked to communicate a review request to another service, together with conveying basic clinical information such as the troponin results and the history and symptoms ascertained from Mrs A’s earlier examination. In contrast, Mr D said that it would not have been normal practice for him as a TI to discuss with other specialists matters related to further patient management or disposition.
106. Emergency medicine specialist Dr I, who wrote the DHB’s SAER report, said that the use of the TI as an intermediary in discussions with the Cardiology team does not represent an appropriate level of communication between services regarding definitive care and disposition decisions.
107. Dr B submitted that under his instruction, Mr D asked Cardiology twice to review Mrs A after receiving each of the troponin results. He said that on both occasions, Mr D then relayed to him that Cardiology had declined to review Mrs A as an inpatient, and that on the second occasion Cardiology had directed them to refer Mrs A to the outpatient clinic. However, Mr D recalled contacting Cardiology on only one occasion, and his recollection is supported by the Cardiology registrar, Dr G, who also recalled only one discussion about Mrs A with Mr D. Furthermore, both Dr G and Mr D recalled that the content of that discussion related only to how to organise an outpatient echocardiogram.
108. There was no documented record of any instruction given to Mr D by Dr B at any time in Mrs A’s care, or regarding any of the specific actions that Dr B said Mr D carried out when liaising between ED and Cardiology.
109. The available evidence suggests that only one discussion took place between Mr D and Cardiology, and that it was only in relation to ordering an outpatient echocardiogram and did not involve the troponin results or reviewing Mrs A as an inpatient. There is insufficient evidence in support of Dr B’s stated recollection regarding instructions given to, actions taken by, and communication from, Mr D. Therefore, I find that it is more likely than not that only one discussion took place between Mr D and Cardiology, regarding outpatient echocardiography.
110. Given the above, I also find it more likely than not that Cardiology was not told about the troponin results (which should have occurred), was not asked twice to review Mrs A after the initial discussion with Dr B, and did not recommend Mrs A’s referral to the outpatient clinic. In addition, although Dr B submitted that the second troponin test was ordered at Cardiology’s request, there is no corroborating evidence of this and it appears uncertain why or by whom the second troponin was ordered.
111. Of note, the clinical plan documented at 10.18am stated “1. Bloods 2. Await repeat troponins 3. ? Cardiology outpatient referral for new murmur” and, lastly, noted Mrs A’s medications. This plan was written about 15 minutes before the second troponin results were known. Dr B’s recollection was that under his direction Mr D had asked Cardiology to review Mrs A following the second troponin result, but this is not recorded in the clinical plan (which Dr B later signed off as being “to [his] design”). As a result, Dr B’s own documented plan does not corroborate his recollection that Cardiology would have been asked to consider Mrs A’s second troponin result with a view to inpatient admission.
112. I am critical that due to the lack of an adequate contemporaneous record about Mrs A’s care, there is still significant uncertainty around precisely what happened during Mrs A’s time in the ED at various stages. There appears to be agreement, however, that Mrs A should have been considered for admission as an inpatient instead of being discharged. This was the conclusion of Dr B, the MCDHB critical incident review, cardiologist Dr J, and ED specialist Dr I.[24] On the basis of comments from several of the above about Mrs A’s clinical information, I believe her clinical needs would have warranted admission. However, for Mrs A to have first been considered for admission, that would have required necessary steps being taken to ensure that there was a mutual understanding between ED and Cardiology that she had been referred to Cardiology for review, which did not occur. Ultimately, Dr B was the clinician responsible for Mrs A’s care until such time as another hospital department accepted responsibility for her ongoing care.
113. While I have made certain findings above based on the evidence that supports that Mr D and Cardiology were not involved to the extent that Dr B recollects, I am nevertheless open to the possibility that there could have been miscommunications, which may have contributed to Dr B believing that certain actions had been taken at the time, when in fact they had not. It is also possible that systemic issues contributed to Dr B’s decision to discharge Mrs A and accept outpatient referral as the outcome. This is discussed further below.

Recurrent chest pain

114. Dr B does not recall having been made aware of Mrs A’s recurrence of chest pain that occurred around 9.50am, or that Mrs A had been given two puffs of GTN for the pain. RN F advised HDC that the GTN should have been documented in the medication chart for a doctor to sign or put under a verbal order (as per the GTN standing order protocol), but in this case the GTN was not charted for Dr B to review. Dr B said that had he known about the further episode of chest pain, he would have asked for the information to be relayed to Cardiology.
115. The ECG taken at 9.53am in response to the chest pain was signed by Dr B six minutes later at 9.59am. RN F commented that because Dr B reviewed and signed the ECG, this indicates that the chest pain would have been escalated to him at that time. In contrast, MCDHB told HDC that based on the clinical notes, it does not appear that the recurrence of Mrs A’s chest pain was escalated to a doctor.
116. There is a question regarding whether Dr B was made aware of the recurrent chest pain. The only evidence to suggest that Dr B did know about the recurrent chest pain appears to be the fact that he signed the ECG that was taken to investigate it. However, given Dr B’s and MCDHB’s responses, and the lack of additional clinical documentation to support that Dr B was made aware, it is not sufficiently clear that he did consider the ECG within the context of the recurrent chest pain. On the whole, it appears more likely than not that he was not made aware.
117. Dr B said that had he known about the recurrent chest pain, he would have asked for that information to be passed on to Cardiology. As I have found that Dr B was likely not made aware of Mrs A’s recurrent chest pain when it occurred, I am therefore not critical of any omission by him to factor this information into his decision-making around Mrs A’s care.

Relevant system issues

118. Mrs A’s care initially followed the Accelerated Chest Pain pathway. However, it is clear from the information gathered during this investigation that there were inconsistencies in how clinicians in different teams were applying the pathway in practice, and how closely they were adhering to it. Although the pathway guided clinicians to refer for inpatient admission any patient who had a troponin result greater than 14ng/L that was not chronic, MCDHB’s ED Medical Lead, Dr H, confirmed that there had been an “informal agreement” in place between ED and Cardiology for several years that had developed to a stage where often even patients with two troponin results of up to 50, but with no significant difference between the results, would be discharged. ED staff had not been consulted about the above informal understanding between departments, and Dr E said that he was not aware of it.
119. Dr B submitted that Mrs A’s care occurred in the context of “long-term diagnostic creep paired with under-resourced departments”. In relation to this, he stated that his acceptance of Mrs A not getting a Cardiology review “was likely influenced by [his] experience of it being common for the Cardiology team to either decline to physically review patients or, following review, decline inpatient admissions”.
120. The above issues are concerning, and speaks to the impact of resource constraints on clinical decision-making, but also in relation to inadequate communication between staff and departments. This is discussed further in my opinion section on MCDHB (below).

Dr B’s reflections

121. Dr B has acknowledged that his documentation relating to Mrs A’s care, including discussions with the Cardiology team or any disagreement to investigate Mrs A as an outpatient, was not optimal or best practice. Dr B considers that this may have been due to competing demands.
122. Dr B reflected that the outcome may have been different had there been clearer communication with Cardiology at the initial discussion in ED about who was responsible for following up on the first troponin result. He also noted that as he had earlier left Mrs A and her family with the plan that Cardiology would be involved in her care, he should have updated them when this did not happen.
123. I acknowledge the extensive effort undertaken by Dr B in completing his wider research into patients like Mrs A who are discharged with two positive troponin results, in order to learn from these events and contribute to systemic improvements.

Conclusion

124. As the clinician primarily responsible for Mrs A’s care, Dr B was responsible for ensuring that there was an appropriate record of the care she received while under his care, and this would have enabled a more straightforward review of the care she received. Dr B accepts that his documentation of Mrs A’s care and related discussions was substandard. I can understand that competing demands at the time (as illustrated by the ED’s “Yellow” status from 10.45am) may have contributed to that but the omissions remain unacceptable.
125. The most serious issue of concern in this case is that Mrs A was not reviewed by Cardiology, and, as a result, was not considered for admission when the consensus is she should have been. For Mrs A to have been considered for admission, there needed to have been a referral from Dr B to Cardiology and, as noted above, it is clear that there is inconsistent evidence, indicative of a communication breakdown between Cardiology and ED about when and if that referral had occurred.
126. Overall, I accept that Dr B identified that Mrs A should have been considered for admission, but I am not satisfied that he took sufficient steps to ensure that this happened before she was discharged. However, even if Dr B had advocated further for Mrs A to be reviewed by Cardiology for consideration of admission, it seems that because of the practice of generally not admitting patients like Mrs A who had had two troponin results under 50ng/L (not chronic and with no significant rise between them), Mrs A may still have been declined admission. It is unclear what safety-netting advice Dr B gave to Mrs A before discharge (such discussion is not documented), but I note that Mrs A was referred with urgent priority to the Cardiology outpatient clinic shortly after her discharge, which in my view shows an appropriate consideration of Mrs A’s clinical needs once Dr B felt that she was not going to be admitted as an inpatient.
127. I consider that Dr B has reflected appropriately on the care he provided in this case, and on how to improve his practice in future. His in-depth audit concerning the management of hospital patients with high troponin results is commendable. These matters temper my criticism of Dr B in this case, and I have factored them into my decision. For the above reasons, I find that Dr B’s actions or omissions do not amount to a breach of the Code of Health and Disability Services Consumers’ Rights (the Code).

 

Opinion: MidCentral District Health Board — breach

128. As a healthcare provider, MCDHB was responsible for providing services in accordance with the Code, and for having in place appropriate systems for its staff. This case raises several issues, including communication between staff, documentation, and having systems that support clinicians to provide the care that patients require.

Documentation

129. I am very concerned about the instances of poor documentation in this case that spanned a number of staff involved in Mrs A’s care. In addition to Dr B’s record-keeping discussed above, Dr E acknowledged that he should have documented his conversation with Dr B in the clinical notes at the time, and RN F should have recorded the GTN spray in the medication chart around the time of Mrs A’s recurrent chest pain. MCDHB told HDC that the lack of documentation of discussions and medical decision-making is “disappointing and is not accepted practice”.
130. This case demonstrates the importance of clinicians maintaining full and accurate records of the care provided. The deficiencies in documentation by MCDHB staff have contributed to an unacceptable degree of uncertainty about what occurred during periods of Mrs A’s hospital stay.

Systemic factors contributing to error

131. I am critical that Mrs A was not considered for admission when this was necessary. As discussed above, it appears that this omission stemmed from the miscommunication between Cardiology and Dr B as to whether Dr B had made a referral or request for Cardiology to review Mrs A. Moreover, on the basis of comments from several of the above about Mrs A’s clinical information, I believe her clinical needs would have warranted admission. However, there are concerning issues regarding inappropriate resourcing and systems in place that appear to have created a barrier to Mrs A receiving the care she required. This is discussed below.
132. It is clear that communication between the clinicians involved in Mrs A’s care about the need for her to be reviewed for admission was inadequate. While at an individual level, Dr B was the clinician primarily responsible for ensuring that a referral had taken place for Mrs A to be reviewed for admission, there were also failures in MCDHB’s systems and practices that contributed to Dr B not being supported in his duties appropriately. In my view, MCDHB’s system should have been better set up to address instances when an ED consultant is uncomfortable with any (perceived) decision by another specialist not to review a patient for admission. Had protocols been in place at MCDHB at the time of Mrs A’s care to guide ED consultants about what to do in such cases, this could have assisted Dr B to take appropriate steps in Mrs A’s care prior to her discharge.
133. Dr B submitted that his acceptance of Mrs A not being reviewed by Cardiology was “likely influenced by [his] experience of it being common for the Cardiology team to either decline to physically review patients or, following review, decline inpatient admissions”. MCDHB’s ED Medical Lead, Dr H, explained that there was an informal agreement with Cardiology that admitting every patient with chest pain who had a troponin greater than 14 would be too much of a burden for their already stressed services. He said that practices had developed whereby often Cardiology or Internal Medicine would refuse to accept patients with a troponin under 50ng/L, and they would recommend a second troponin test and discharge if there was no significant rise from the initial troponin test. He confirmed there had been no formal consultation or agreement with ED about that practice.
134. I am critical that there was an unofficial practice in place among MCDHB staff that appears to have developed in a somewhat ad hoc way in response to resourcing pressures, with the effect that patients who required admission on the basis of the clinical information available were being turned away inappropriately. It also appears that the persistence of this informal practice contributed to a culture of acceptance by ED staff that Cardiology and Internal Medicine would sometimes not accept for admission some eligible patients who in a more adequately resourced environment would have been admitted — and a consequent reluctance by ED staff to advocate for admission.
135. I am critical that the above unofficial systems resulted in patients such as Mrs A receiving less assessment and fewer clinical investigations than indicated by their clinical results. I am also critical that such a system was allowed to continue for a considerable time without being addressed formally via an update to the ACPP or other means as appropriate.
136. For the reasons set out above, I consider that MCDHB was responsible at a service level for its system and communication breakdowns that led to the failure to review Mrs A for admission. The system allowed for clinical decisions to be made with too much weight given to resourcing capacity considerations, and not enough to the clinical needs of patients. I consider that the quality of Mrs A’s care suffered as a result of this, and that MCDHB’s systems were a key contributing factor to the inadequate service she received. Accordingly, I find that MCDHB failed to provide Mrs A with service of an appropriate standard and breached Right 4(1) of the Code.[25]
137. I am pleased to see that following these events, positive systemic changes were implemented at MCDHB to address many of the issues raised in this report (discussed below).

 

Changes made since events

MCDHB

138. MCDHB’s Serious Adverse Events Governance Group approved an action plan to ensure that learning from this incident is applied consistently across the organisation. The following actions were implemented:
     1. Training and orientation on the ACPP for new medical staff.
     2. Review of the clinical oversight expectations for TIs and SHOs in the ED.
     3. Dissemination of the expectations of clinical documentation to all staff, with an information sheet on the same provided to all new TIs.
     4. Inclusion of quantified troponin values and trends in the ACPP flow chart.
     5. A “Speaking up for Safety” programme for clinical staff at all levels to support them to uphold the duty of advocacy for patients.
139. MCDHB acknowledged that there had been facility and workforce resource constraints within the ED, and outlined a number of actions completed and underway to ameliorate these issues, including:
     1. In May 2020, the Board approved a plan for establishing four pods adjacent to the ED, which will accommodate 20 acute medical assessment beds/chairs and 10 ED observation beds/chairs, which will provide increased short-term capacity for the ED to cope with growing demand.
     2. MCDHB began a new project called SPIRE (Surgical Procedural Interventional Recovery Expansion),[26] which will improve patient health journeys and outcomes, including by providing better access to surgical care, safer preoperative and postoperative spaces, and rapid diagnosis and earlier intervention for people with cardiac conditions.
     3. Additional cardiologists were recruited to improve the Cardiology service. The ED also recruited an additional five emergency medicine specialists and additional registered nurses. Furthermore, the ED now has a nurse practitioner, and it is expected that the number of nurse practitioners will increase in coming years.
140. MCDHB said that the ED and Cardiology departments have met and continue to discuss clinical care and pathways for patients on a regular basis. MCDHB noted that the relationship between the two departments has improved since Mrs A’s care.
141. In relation to the lack of documentation of discussions and medical decision-making in this case, MCDHB stated that Dr H has led refresher sessions for medical staff as part of their ongoing education, with a focus on clinical documentation.

Dr B

142. Dr B told HDC:

“I try to constantly appraise where I have failed my patients what the source of that error is (bias, simple mistake, interruption, legible writing etc) and how to improve it. This process is essential to a self-regulating striving physician. Since [Mrs A’s] unfortunate outcome I have made some personal system changes and I am working toward broader changes at the DHB.”

143. In relation to broader changes at the DHB, Dr B told HDC:

“Access to cardiology diagnostics, access to general medical beds and access to cardiology reviews have all been improving slowly in the face of the severe pressures of the current winter. I believe this case was a nidus for us ([all]) to work on focused aim. The SPIRE rebuild at Midcentral has an interventional cardiology catheterisation lab in it. Which will decompress the wait to be transferred to Wellington for interventions, this is two years out. I have also written the Chest Pain and Discomfort Pathway for Hospital Health Pathways and remained on with them as a clinical editor.” 

144. In relation to improvements in communication, Dr B told HDC that the hospital now has an electronic whiteboard for whole-of-hospital communication to aid physicians and nurses in tracking requests for reviews and their outcomes in real time.
145. In respect of his own practice, Dr B stated:

“I have stepped up my communication and my documentation of communication. When my plans are not expressly followed by a [SHO], registrar, mentoring colleague or [TI] and I feel communication has been the reason, then I have removed communication through registrars or any other intermediary and spoken directly to another consultant. It is my responsibility as a consultant to have zero tolerance for deviation from my plan for the patient.”

146. Dr B told HDC that he has changed his usual practice at the time of Mrs A’s care of not documenting his calls to admitting services when asking them to review a patient. Dr B said that in such circumstances he now notes explicitly to whom he has spoken, “so it cannot be later forgotten or denied”. He further stated that he is now “taking more time to document deviations from any of [his] care plans, especially when it is with regards to requests by other services. … When a plan changes and I chase it up with inpatient teams I do so for the patients as well.”

 

Recommendations

147. I recommend that Te Whatu Ora|Health New Zealand consider utilising this case in the training of its staff on the importance of adequate documentation, communication, referrals to specialist services, and other relevant matters. Te Whatu Ora is to report to HDC on the outcome of this consideration within two months of the date of this report.
148. I recommend that, within three weeks of the date of this report, Te Whatu Ora|Health New Zealand and Dr B provide a joint written apology addressed to Mrs A’s family, in which the issues and criticisms identified in this report are acknowledged. The draft apology should be provided to HDC initially, for forwarding to Mrs A’s family once finalised.
149. In light of the actions already taken by Te Whatu Ora|Health New Zealand and Dr B since these events (as outlined above), I am satisfied that no further recommendations are required.

 

Follow-up actions

150. A copy of this report will be sent to the Coroner.
151. A copy of this report with details identifying the parties removed, except MCDHB (now Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral), will be sent to the Medical Council of New Zealand, and it will be advised of Dr B’s name.
152. A copy of this report with details identifying the parties removed, except MCDHB (now Te Whatu Ora Te Pae Hauora o Ruahine o Tararua MidCentral), will be sent to the Health Quality & Safety Commission and placed on the Health and Disability Commissioner website, hdc.org.nz, for educational purposes.

 

Appendix A: Accelerated Chest Pain Pathway

 

 

[1] On 1 July 2022, the Pae Ora (Healthy Futures) Act 2022 came into force, which disestablished all district health boards. Their functions and liabilities were merged into Te Whatu Ora|Health New Zealand. All references in this report to MidCentral District Health Board (MCDHB) now refer to Te Whatu Ora MidCentral.

[2]  Since the events in this report, Mr D has qualified as a doctor.

[3] Simvastatin.

[4] Relating to blood circulation.

[5] Reduced blood flow (and thus oxygen) to a part of the body.

[6] A type of protein that appears in the blood only when the heart muscle has been damaged (eg, following a heart attack).

[7] A MOSS is a doctor who is yet to specialise or gain a postgraduate qualification, or an international medical graduate who has an overseas postgraduate qualification but is not yet eligible for a consultant role.

[8] Dr B told HDC that the times recorded for blood results are not the same as the times at which those results became available to ED staff on the electronic record for review. Dr B stated that the times at which results become available on the electronic record are not captured.

[9] Dr B told HDC that the times on these records are not accurate, and that the times represent only when information is entered into the system. He stated: “In a busy ED this is not necessarily contemporaneous with the events being described. Doctors will often make handwritten notes that are later inputted to the system, or else type notes into a blank document that is later copied and pasted in to the system.”

[10] A heart murmur is a sound made by the blood flowing through the heart’s valves. Often it can be harmless, but sometimes it can be a sign of a serious heart condition.

[11] In particular, one part of the provisional plan was to “[a]wait repeat troponins”. However, by the time of Mrs A’s initial examination by Mr D and Dr B, the result of the initial troponin test was still pending, and no decision had been made at that time to order a repeat troponin test.

[12] As per footnote 9, the typed medical notes for the examination would in themselves have been written only around 1.5–2.5 hours after the examination itself.

[13] MCDHB stated that the ACPP at the time was based on the National ACPP.

[14] Nanograms per litre. A nanogram is one billionth of a gram.

[15] Whether the patient gets admitted or discharged.

[16] The words “Emergency Department” are typed under the “Requestor” section of the bloods form.

[17] Glyceryl trinitrate.

[18] MCDHB told HDC that this gives nurses the ability to care for a patient’s acute pain when a doctor may not be immediately available to write the medication order.

[19] Dr B stated: “Because of where the GTN was documented [the ED nursing notes], this may not have been available for me to see. My normal practice would be to review the drug chart.”

[20] The referral stated a referrer priority timeframe of “within 2 hours”, and a radiology priority timeframe of “within 6 weeks”.

[21] A group of conditions in which the demand of the heart muscle for oxygenated blood exceeds the supply of oxygenated blood by the coronary arteries.

[22] The build-up of cholesterol or fats in and on the artery walls, causing a narrowing of the arteries and obstruction of blood flow.

[23] That is, ED patients with chest pain who have had two elevated troponins (more than 14ng/L but less than 50ng/L with no significant change between them) and were discharged home.

[24] See paragraphs 80, 81, 84 and 86.b).

[25] Right 4(1) states that that every consumer has the right have services provided with reasonable care and skill.

[26] Surgical — increasing from seven to nine theatres; Procedural — increasing from two to four procedure rooms; Interventional — establishing a new Cardiac Catheterisation Laboratory; Recovery — improving the perioperative suite to support all patient streams; Expansion — of other supporting clinical and non-clinical resources.