Names have been removed (except Health NZ, Health NZ Waitematā, North Shore Hospital and the advisor) to protect privacy.  Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

Complaint and investigation

Information gathered during investigation

Opinion: Health NZ Waitematā — breach

Changes made since events

Recommendations

Follow-up actions

Appendix A: Independent clinical advice to Commissioner

Complaint and investigation

1. The Health and Disability Commissioner (HDC) received a complaint from Ms B and Mrs A about the care provided to their late father and husband, Mr A, by Waitematā District Health Board (now Health New Zealand|Te Whatu Ora (Health NZ) Waitematā).[1] The following issue was identified for investigation:

• Whether Health New Zealand|Te Whatu Ora Waitematā provided Mr A with an appropriate standard of care in Month6[2] 2020.

2. This report is the opinion of Carolyn Cooper, Deputy Commissioner, and is made in accordance with the power delegated to her by the Commissioner.
3. The parties directly involved in the investigation were:

Ms B                                                                             Complainant/daughter

Mrs A                                                                           Complainant/wife

Health NZ Waitematā                                            Provider

4. Also mentioned in the report:

Dr D                                                                       Respiratory physician

Dr E                                                                       Consultant physician

5. Further information was received from:

RN C                                                                      Registered nurse

The Office of the Coroner[3]

6. Independent clinical advice was obtained from an internal medicine specialist, Dr Richard Shepherd (Appendix A).

Information gathered during investigation

Introduction

7. Mr A, aged in his seventies at the time of events, presented to North Shore Hospital on 8 Month6 with symptoms of light-headedness, chest pain, shortness of breath (SOB) and possible haematemesis (vomiting of blood). He was stabilised in the Emergency Department (ED) and admitted to a medical ward on 9 Month6 with unstable angina,[4] having a background of severe ischaemic heart disease (IHD),[5] pulmonary hypertension,[6] cor pulmonale,[7] and chronic obstructive pulmonary disease (COPD)[8] with a component of asthma.
8. Mr A was discharged on 18 Month6. Following discharge, his condition deteriorated rapidly, and he was re-admitted to hospital the following day after becoming increasingly short of breath overnight. Following a hypotensive[9] event and cardiorespiratory arrest, resuscitation attempts were unsuccessful, and, sadly, Mr A passed away on 19 Month6. I take this opportunity to extend my sincere condolences to Mr A’s family and friends.

Events leading up to complaint

9. In his report to the Coroner, Mr A’s general practitioner (GP) stated that Mr A had ‘quite an extensive medical history’, including severe IHD, a myocardial infarction (heart attack) in 2008, and a nephrectomy[10] for a poorly functioning kidney. Mr A was on long-term medication, including atorvastatin,[11] losartan,[12] and propranolol[13].[14]
10. The GP reported that Mr A had been diagnosed with moderate to severe COPD in 2013, after which he would ‘typically’ see Mr A 2–3 times per year for exacerbations of his COPD. The GP stated that during 2020, Mr A’s exacerbations of COPD increased, and therefore he referred Mr A to a private respiratory physician, Dr D.

Appointment with Dr D — Month1

11. Mr A attended an appointment with Dr D on 20 Month1. Dr D noted in the clinic letter that Mr A had known significant cardiac and respiratory disease; his dyspnoea (difficulty breathing) had escalated in the last six months; he was ‘unable to walk on the flat without becoming significantly breathless’; and he had a continuing cough. Dr D documented that on examination, Mr A ‘managed two flights of stairs with oxygen saturation maintained at 95% on room air’.
12. Dr D documented that Mr A had a raised BNP[15] that suggested the development of heart failure, particularly in the context of known pulmonary hypertension and IHD, which could have been contributing to his breathing difficulties. In addition, Dr D noted that Mr A was on long-term propranolol for intractable migraine and that past trials of alternative medication had been unsuccessful. Dr D discussed with Mr A that the propranolol was likely exacerbating his breathing difficulties, with a view to reducing it slowly ‘[a]t some point’.
13. Dr D noted that Mr A had both ischaemic heart disease and COPD/asthma overlap. Dr D prescribed roxithromycin[16] for Mr A’s cough and requested CT scans of his chest and sinuses, formal lung function and 6-minute walk tests, an echocardiogram (ECHO)[17] and ‘perhaps a right heart catheter test’, to be performed at North Shore Hospital. Dr D noted in the clinic letter: ‘If significant desaturation is demonstrated [Mr A] may be a candidate [my emphasis] for portable oxygen.[18]’ Dr D also noted that Mr A would be seen again following the results of the tests.[19]

Natural ozone concentrator

14. The complainants told HDC that Mrs A purchased a ‘natural ozone concentrator[20]’, which came with nasal prongs and a pulse oximeter, for Mr A around six months prior to his death, ‘as she was desperate to have anything to help [him]’. The complainants stated that ‘[t]hey followed the instructions that were included with the machine as best they could’ and that Mr A used this daily when he was getting short of breath, for around 15 minutes each time.
15. Health NZ Waitematā stated that ‘[Dr D] was not consulted, nor [Dr D’s] advice sought regarding this purchase’.

Presentation to ED — 8 Month6

16. Mr A presented to North Shore Hospital via ambulance at 6.09pm on 8 Month6, following a short period of witnessed altered consciousness, preceded by a sudden onset of severe nausea, clamminess, SOB, severe central chest pain radiating through to between his shoulder blades, and possible haematemesis after reportedly trying to get his new mobility scooter in and out of the car.
17. Clinical notes show that Mr A reported ‘a significant decline in functional ability’ over the previous two months, with fatigue, SOB (‘struggling to walk 10m’), nausea on exertion or eating, and recurrent episodes of central chest pain ‘often radiating to between [his] shoulder blades’. However, the complainants stated that prior to admission, Mr A had been able to go about his normal activities of daily living, ‘even mowing lawns right up to a couple of days before his admission to hospital’.
18. On admission, Mr A’s blood pressure (BP) was (129/80mmHg[21]), he was bradycardic[22] with a heart rate (HR) of 55 beats per minute (bpm), and tachypnoeic[23] with a respiratory rate (RR) of 21 breaths per minute.[24] Mr A’s oxygen saturation level (SpO₂) was documented as 94% on 3 litres per minute (L/min) of supplemental oxygen (O₂).[25]
19. Clinical notes show that in ED, Mr A’s chest pain and nausea resolved, he reported no back pain, and his breathing returned to normal. An arterial blood gas (ABG)[26] test showed that Mr A was not retaining carbon dioxide (CO₂),[27] with normal levels of CO₂, O₂ and acidity (pH levels) in his blood.[28] An electrocardiogram (ECG) was undertaken, which confirmed sinus bradycardia, as well as a chest X-ray and computed tomography (CT) scan, which found emphysematous[29] changes in his lungs. His blood tests showed an elevated creatinine level (170µmol/L)[30] and troponin level (43ng/L).[31]
20. The clinical impression was noted as:

• Severe chest pain on a background of recurrent episodes, progressive SOB and known IHD;
• Syncopal episode (fainting), likely secondary to severe pain, hypotension and possible hypoxia[32] in the setting of known COPD;
• Acute kidney injury (AKI), possibly due to hypovolaemia;[33]
• Shortness of breath, likely multifactorial; and
• Episode of haematemesis.

O₂ use at home

21. The ED admission summary noted that Mr A used ‘home O₂ intermittently’, and in a report to the Coroner dated 28 Month8, Dr E, a consultant physician, documented: ‘[Mr A] reported having supplemental oxygen at home which he was using several times a day when he felt short of breath.’
22. In contrast, the complainants stated that Mr A did not have (prescribed) O₂ at home[34] and he was never formally assessed for the need for short-term or long-term O₂ at home. The complainants told HDC that during Mr A’s admission in ED (and on the general medical ward to which he was transferred subsequently), Mrs A ‘made it clear to the hospital’ that Mr A did not have O₂ at home.

Care provided during hospital admission

9 Month6

23. Mr A was admitted to a general medical ward on the morning of 9 Month6 with a primary diagnosis of unstable angina (chest pain), on a background of IHD.
24. Health NZ told HDC that due to his underlying condition (of COPD), Mr A’s ‘usual’ oxygen saturation was between 88–92%. The ward admission summary documented: ‘[U]ses Oxygen 3–4 x per day for SOB … accept Spo2 88–92% given known COPD. Prefer closer to 92.’
25. In the morning, Mr A was reviewed by Dr E, who noted that he was ‘[b]reathless at rest’ and that over the past three months he had become lethargic and short of breath with minimal activity. In the report to the Coroner, Dr E documented that Mr A stated that he had seen Dr D, and Dr E requested a copy of Dr D’s correspondence ‘to get more information on recent developments and investigations’.
26. Dr E’s report to the Coroner stated that due to Mr A’s extensive cardiac history, and his most recent transthoracic echocardiogram (Month3) showing ‘significant deterioration in right ventricular function’, a cardiology review was requested.
27. In the afternoon, Mr A was seen by a cardiology registrar, who examined Mr A’s chest and documented: ‘[G]lobally reduced [air entry] and expiratory wheeze throughout.’ Mr A’s troponin level had increased to 46ng/L (indicating a cardiac condition), and the registrar noted that he would discuss the need for an angiogram[35] with the senior medical officer (SMO). Isosorbide mononitrate (ISMN)[36] was prescribed for Mr A’s IHD and was started the following day.

10–11 Month6

28. Clinical notes show that Dr D emailed the clinic letter (dated 20 Month1) to a general medicine house officer (GMHO) in the morning of 10 Month6. The GMHO summarised the contents in the clinical notes, in particular Mr A’s IHD, COPD/asthma overlap, chronic cough, and heart failure in light of his increased BNP. A plan to wean Mr A off propranolol was also noted, ‘as it [was] likely [exacerbating his] SOB’.
29. However, the GMHO did not document the comment in Dr D’s clinic letter that Mr A might be a candidate for portable oxygen if significant desaturation was demonstrated on formal lung function and 6-minute walk tests, and that Dr D would see him again following the results of tests. These tests had not been conducted at the time of Mr A’s admission in Month6.
30. On 10 Month6 Mr A was reviewed by a general medicine registrar (GMR), who documented, ‘Respiratory clinic letter noted,’ and that Mr A was ‘on intermittent home oxygen’. It was also noted that Mr A’s AKI was improving, with his creatinine level having dropped to 141µmol/L.
31. On the evening of 10 Month6, Mr A was noted to be hypothermic[37] and was reviewed by a GMHO, who found no change in chest findings on examination and no drop in SpO₂ levels. Clinical notes show that Mr A told the GMHO that he ‘normally use[d] O₂ at home — 15 min bursts [three times a day], known to have SpO₂ 86–90% according to him’. The GMHO noted the admitting target saturation levels of 88–92% O₂ (as per paragraph 24) and documented: ‘[S]till aiming for SpO₂ 92–96%.’ The GMHO requested a chest X-ray and blood test, as it was thought that the hypothermia could be secondary to an infection.
32. The chest X-ray taken that evening showed possible pulmonary oedema,[38] and intravenous (IV) antibiotics (cefuroxime) were started. However, the blood results received the following day (11 Month6) were ‘unconvincing for [an] infection’, and the IV antibiotics were ceased, with oral antibiotics (roxithromycin) re-commenced.
33. In the afternoon of 11 Month6, Mr A was reviewed by the cardiology registrar, who determined that due to his comorbidities, an angiogram would not be in his best interest. Furthermore, Dr E stated in the report to the Coroner that ‘no further investigation or interventional measures for ischaemic heart disease could be planned’. Instead, Mr A was started on ‘medical management only’ for unstable angina.
34. Health NZ stated that Dr E recalled making it clear to Mr A that ‘his medical issues were severe and not reversible and that the aim of management was to minimise his symptoms and optimise his function’.

13–15 Month6

35. On the morning of 13 Month6, Mr A’s BP and HR were low, and he was reviewed by a GMHO, alongside a nurse from the critical care outreach team (CCOT). The GMHO noted that Mr A’s BP had improved, but that he was lightheaded and nauseous and had had poor oral intake and brief left-sided chest pain earlier that morning. In addition, Mr A was very short of breath.
36. Mr A was administered O₂ via high-flow nasal prongs (HFNP),[39] and the GMHO documented: ‘[A]im sats >94% (not retainer as previous ABGs).’ In contrast, the CCOT nurse documented: ‘[M]aintain target saturations > 92% as per team notes.’ IV antibiotics were restarted, the ISMN was withheld ‘due to low BP’, and a repeat chest X-ray and blood tests were ordered.
37. The chest X-ray showed ‘severe widespread emphysema, and density within the right lower zone’ and the development of a small right-sided pleural effusion.[40] Mr A’s blood test showed worsening of his AKI (creatinine 217µmol/L) and increased troponin levels. The clinical impression was hospital-acquired pneumonia,[41] with secondary type 2 myocardial infarction[42] and AKI, ‘likely secondary to significant dehydration’. As a result, Mr A’s regular losartan medication was withheld (‘due to AKI’),[43] with diuretics and anticoagulants[44] prescribed.
38. Mr A was reviewed by a GMHO and a CCOT nurse at around 2am on 14 Month6, as he was hypotensive. The CCOT documented that O₂ via HFNP should continue, aiming for saturations of 92–96% O₂. The GMHO re-prescribed ISMN ‘as tolerated’ for chest pain. However, in the afternoon, clinical notes by the GMR show that Mr A was not tolerating the ISMN or HFNP and he was given regular nasal prongs instead.
39. In the morning of 15 Month6, Mr A’s HR and BP were stable, and his AKI had improved slightly (creatinine level 191µmol/L). Mr A reported feeling constipated and was reviewed by Dr E, who noted that this was an ‘adverse reaction’ to the ISMN and directed that this be withheld until Mr A’s bowels had cleared, after which a lower dose would be trialled.

16 Month6

40. At around 4am, a registered nurse found Mr A in the toilet and noted that he was ‘very short of breath’. He was started back on HFNP, with a plan to ‘wean O₂’; however, clinical notes in the afternoon show that Mr A was not tolerating this and became desaturated, so he was put back on HFNP. His SpO₂ level at this time was 92% on 2L/min O₂ and it was documented to ‘[a]im [for] sats [of] 92–96%, [and to] wean O₂’.
41. In the afternoon, a GMHO and a CCOT nurse were called to review Mr A as his SpO₂ level had decreased to 88% on 2L/min, and he was hypotensive and light-headed. The GMHO noted that Mr A appeared short of breath but was ‘saturating 88–90’ on 3L/min of O₂ on HFNP.[45] The clinical impression was that his hypotension was likely causing his symptoms, including his ongoing O₂ desaturations. IV fluids were charted, and the target saturations were set at 92–96% O₂, with the GMHO documenting ‘not a CO₂ retainer’. In contrast, the CCOT nurse who reviewed Mr A after the GMHO documented: ‘Aim sats 88+ as at high risk of CO₂ retention’.

17 Month6

42. At 9.33am Mr A was seen by Dr E, who noted that he looked ‘much improved’ and that his episodes of hypotension and desaturations from the previous day were improving. Dr E’s report to the Coroner stated that Mr A’s vital signs had improved, and a chest examination revealed better air entry with no wheeze. Mr A had received a reduced dose of ISMN that morning, and Dr E documented that this would be ceased ‘due to low BPs’. In addition, IV antibiotics were ceased, with oral antibiotics (cefaclor and roxithromycin) continued.
43. Dr E’s report to the Coroner also stated that Mr A ‘was keen to go home before the weekend’. Dr E documented in the clinical notes: ‘If stable, [discharge] over weekend, otherwise aim [discharge] next week.’ Health NZ told HDC that Mr A was ‘distressed and ba[u]lked when [Dr E] told him it would be best if he stayed a few more days until after the weekend to be more certain of his stability on his current medication regime’. Health NZ stated that Mr A expressed wanting to go home … as it ‘may be his last’, and, given this, Dr E ‘reached a compromise with [Mr A] that if his vital signs were stable on 18 [Month6] he could be discharged’.
44. At 4am Dr E noted Mr A’s SpO₂ level of 93% on 3L/min O₂ and documented: ‘Wean down O₂.’ Mr A was to be taken off HFNP (and given regular nasal prongs), with target saturations of ‘92–96%’ O₂. However, Dr E’s report to the Coroner stated that ‘[a]s [Mr A] stated he had supplemental oxygen at home, the target was an oxygen saturation of >90% on no more than 2L/min of supplemental oxygen’.
45. Health NZ stated that the decision to alter Mr A’s target saturations to 92–96% O₂ was in view of his improving oxygenation and review of his recent and historical ABGs, which showed that Mr A was not a CO₂ retainer. Health NZ told HDC:

‘All patients who are admitted with a diagnosis of COPD, or who can reasonably be assumed to have COPD (heavy smoking history and exercise limitation), and who are hypoxic, should have a prescription for oxygen to target the lower range 88–92% unless or until it is established that they are not CO₂ retainers. At this point the prescription can be changed to the usual target of 92–96%.’

46. The complainants stated that on the afternoon of 17 Month6, Mr A was still on HFNP and RN C told the family that although she was meant to be weaning his O₂, he was not tolerating it. The complainants told HDC that when RN C discussed Mr A’s oxygen requirements with them, in the context that he would possibly need this at home, ‘it was explained to her that in no way we were set up for this, [and] she indicated this would be addressed should it need to occur post discharge’.
47. RN C confirmed to HDC that when the family came to visit, she informed them of the ‘challenge to wean [Mr A] off HFNP’. She told HDC that on HFNP, Mr A ‘saturated 92–94% with fluctuations’ and when she attempted to decrease O₂ by 1 Litre, Mr A ‘desaturated to higher 80s %’. She stated that despite positioning Mr A in ‘Fowler’s (sitting) positions’, deep breathing and ‘a “pursed lip breathing” technique’, the maximum oxygenation level reached was 92% and therefore she considered ‘weaning off unsafe at that moment and returned oxygen level supply to initial values’. RN C documented: ‘[U]nable to wean [Mr A] off HFNP reaching target aim 92–96%. Saturation up to 92% on best effort of deep breathing and sitting position.’
48. RN C told HDC that both Mr A and his family mentioned that he used O₂ ‘intermittently’ at home, with the family stating that the target saturations were 88–92% on 2L/min O₂. RN C documented: ‘Spoke to family regarding oxygen aims: as per family [patient] on 2L O₂ supply at home with aim sats 88–92%.’
49. RN C stated that she was ‘surprised with the differences in oxygen aims, as [she] did not see any information in his notes about [Mr A] having CO₂-retaining form of COPD’ and due to the differences in target saturations, she spoke to a GMHO, who reviewed Mr A’s blood results[46] and verbally confirmed that Mr A’s new target saturations would be 88–92% O₂. RN C told HDC that she informed the family of ‘the new inpatient oxygen level aim’ and documented:

‘[W]riter spoke to HO to clarify the saturation aim and difficulty weaning off [patient] to [nasal prongs], as [patient’s] usual saturation is between 88–92%. HO verbally confirmed new aim 88–92% … Aim sats 88–92%, wean O₂ HFNP.’

50. Clinical notes from 4.40pm show that the GMHO discussed Mr A’s target saturations with the GMR, and it was documented: ‘[T]arget sats to be 90 and over.’ Nursing notes from 9.30pm that evening show that Mr A was taken off HFNP and put onto regular nasal prongs, with target saturations of ‘>90% 0₂’.

Discharge — 18 Month6

51. Dr E’s report to the Coroner states that on 18 Month6, Mr A was ‘clinical[ly] stable’ and his blood tests showed further improvement in his AKI (creatinine 188µmol/L).[47]
52. At 12.21pm, Mr A was seen by a GMHO, and it was noted that he was ‘mobilising well. No complaints [overnight]. Keen to go home.’ The GMHO noted that Mr A’s vital signs were all within normal range, and his SpO₂ levels were 92% on 2L/min 0₂ (without nasal prongs).[48] The GMHO documented that Mr A was ‘safe for discharge’ with ‘[r]eturn advice’ given. Mr A was discharged at 2.13pm on 18 Month6.
53. The complainants dispute that Mr A was mobilising well and stated that on the day of his discharge, Mr A’s ‘level of activity was significantly below normal’, and he needed a wheelchair to get to the car. Health NZ stated that Mr A was taken to the car in a wheelchair ‘for his comfort as although he was mobilising well in the ward his overall exercise tolerance was limited’.
54. Health NZ said that the decision to discharge Mr A ‘was based on clinical improvement and stability’, balanced with his desire to be discharged home. Health NZ stated:

‘Because [Mr A] was alert and mobilising well, he reported being comfortable and had achieved his pre hospital oxygenation (92%) on minimal (2L/min) oxygen the team supported his desire to be discharged.’

55. Furthermore, Health NZ stated that in light of Mr A’s COPD, ‘the issue [was] what baseline (“as good as it gets”) blood oxygen saturation levels were realistic’ and whether these levels could be achieved at home with O₂. Health NZ further stated that it was Dr E’s opinion that >90% blood oxygen saturation on 2L/min ‘was realistic’ and ‘this was one of the crucial parameters which was met that led to clearing [Mr A] for discharge’.
56. Mr A’s discharge summary documented that an outpatient consultation with the Health NZ Waitematā respiratory service had been booked for 11 Month7, together with lung function and 6-minute walk tests. The summary noted: ‘An appointment is due with Respiratory — Dr D. This appointment has not yet been booked.’ It was documented that no general medicine follow-up was needed and that no specific recommendations around GP review had been made, and no discharge advice was documented regarding O₂ use at home. In addition, the discharge summary noted that Mr A was to continue with the oral antibiotics (cefaclor) for a further two days, and the roxithromycin until his appointment with his respiratory physician in Month7.
57. Health NZ told HDC that the lung function and 6-minute walk tests had already been booked on referral from Dr D, and that appointments to see private specialists are to be arranged by the patient. Health NZ also told HDC that timely GP review post-discharge should have been made, and the ‘expected [discharge] advice’ regarding Mr A’s O₂ use ‘was dependent on what he was already on, and what he had been advised to do by [Dr D]. Unfortunately, in hindsight this ha[d] not been clearly established.’

Readmission to hospital — 19 Month6

58. Mr A was readmitted to North Shore Hospital at 8.49am on 19 Month6 via ambulance for SOB. Clinical notes show that Mr A had ‘felt okay’ when discharged the previous day, but he had developed increasing SOB that evening, which worsened overnight. It was noted that on the ambulance’s arrival, Mr A was bradycardic, hypotensive, and hypoxic.
59. Mr A was reviewed by an intensive care unit (ICU) registrar, who documented: ‘Not for ICU … Would not benefit from intubation and suspect that even [non-invasive ventilation] would be of little benefit … Advise that he s[h]ould not be for [cardio-pulmonary resuscitation[49] (CPR)].’[50]
60. An ECG showed evidence of right heart strain and blood tests showed worsening AKI. Mr A was started on IV antibiotics and reviewed by a GMR, who noted that he was ‘hemodynamically stable’; however, during the afternoon, Mr A again became hypotensive and bradycardic, and IV fluids were given. At 4.38pm, the GMR documented that Mr A had ‘obvious’ right heart failure with severe pulmonary hypotension, which made fluid balance ‘exceedingly difficult’. The GMR noted: ‘[In the presence of his AKI] IV [fluids] is likely a double edged sword as it worsens his [pulmonary hypotension].’
61. The GMR discussed Mr A’s case with Dr E, who agreed that ‘ward measures have been carried out and currently at ceiling of care[51] given ICU declined … further deterioration would warrant supportive cares’. Clinical notes show that Mr A’s resuscitation status was changed to ‘Not For CPR’/‘Not for resuscitation’ (NFR) on a ‘Medically Inappropriate CPR’ basis.
62. It is documented that in the evening, the ICU registrar met with the complainants regarding Mr A’s NFR status and declined ICU care and explained that due to his poor respiratory function, COPD, and pulmonary hypertension, if he were to be intubated and ventilated, ‘he would never be able to come off a breathing machine, resulting in distress for him and the family’. Clinical notes show that the complainants were understanding of Mr A’s situation and that he would ‘remain with a ward-level ceiling of care’. However, Health NZ told HDC that it is not recorded whether the ‘concept’ of CPR was ‘specifically discussed or whether the team confirmed that the family fully understood what NFR … specifically meant’.
63. Clinical notes show that Mr A suffered a cardiac arrest at approximately 6.30pm, after becoming increasing cyanotic[52] and short of breath, but that Ms B ‘voice[d] objection to the NFR status earlier determined’ and therefore, a 777 (resuscitation) call was made. Health NZ told HDC that a 777 call was ‘likely’ made as Mr A had not yet been transferred to a medical ward, the timing of his deterioration was sudden, and Ms B ‘was distressed at the rapid turn of events and wanted CPR to commence’.
64. CPR was performed for approximately five minutes; however, a rhythm check showed pulseless electrical activity[53] and 1mg of IV adrenaline was given. Another round of CPR commenced, but Mr A ‘remained in asystole[54]’. It was decided that ‘prolonged CPR was not in [Mr A’s] interest’ and CPR was stopped.
65. Mr A passed away at 6.40pm and the established cause of death was cor pulmonale, secondary to severe COPD.

Further information

The complainants

66. The complainants raised their concerns directly with Health NZ Waitematā via letters; however, their concerns remained unresolved. The information provided in these letters has been included in this report where relevant and appropriate.
67. The complainants are concerned that Mr A did not receive a full respiratory assessment and was not fully weaned off oxygen before being discharged, as he did not have prescribed O₂ at home. The complainants told HDC that they made it ‘very clear’ to the hospital that Mr A did not have (prescribed) O₂ at home, and therefore his ‘baseline’ was ‘NOT on oxygen at home’.
68. The complainants feel that Health NZ ‘negligently discharged [Mr A] into a situation which ultimately led to his death’ and believe that more care should have been taken in his discharge planning. The complainants told HDC that as Mr A was on O₂ for the duration of his admission and ‘was not able to maintain his oxygen saturations to a level that would sustain life’, this led to his cardiac arrest, and their understanding is that Mr A should have been off O₂ for ‘at least 24 hours’ prior to discharge, to ensure that he was able to tolerate ‘being on room air’.
69. Furthermore, the complainants stated that they were not made aware of whether Mr A’s ‘disease process was end stage or if there was reversibility’.

Health NZ

70. Health NZ extended its sincere condolences to the family ‘for the loss of a clearly treasured family member’. Health NZ told HDC that on speaking with its staff, ‘it was obvious that [Mr A] was popular, and they were saddened to hear of his passing’.
71. Health NZ stated that in hindsight, there was a breakdown in communication/ understanding between the staff, Mr A, and his family, which resulted in Mr A receiving care at hospital discharge that did not meet Health NZ’s standards and for which Health NZ sincerely apologised to Mr A’s family. In addition, Health NZ apologised for not ensuring that the family understood the decisions being made, together with Mr A, during the discharge process.
72. Health NZ told HDC that the changes to Mr A’s medications were considered to be appropriate ‘based on the available clinical information and observations at the time’ but acknowledged that there was an opportunity to review his medications in the pre-discharge period, in light of his hypotension, and stated that it would have been appropriate to ‘more proactively’ manage the combination of his propranolol and losartan medications prior to discharge.
73. Health NZ told HDC: ‘Unfortunately, there is no record of a formal assessment of [Mr A’s] need for oxygen prior to discharge, including a review of his oxygen prescription and ability to manage at home.’
74. Health NZ stated that Mr A’s target saturations during his inpatient stay were based on the clinical assessment at the time, although ‘not perfectly executed as use of the hospital’s electronic prescribing of oxygen was not utilized, which it should have been’.
75. Health NZ stated that Mr A was not receiving Long Term Oxygen Therapy (LTOT)[55] prior to his admission, and he ‘would not [have met] national criteria for LTOT’, given the information in Dr D’s clinic letter, which noted a resting room air saturation of 95% (as per paragraph 11). Health NZ told HDC that evidence has shown harmful effects (particularly to the cardio-respiratory system) when LTOT is given to those who do not require it, and stated that in Mr A’s case, ‘domiciliary oxygen is likely to have been at best of no value, but realistically harmful to the patient at that time’.
76. Furthermore, Health NZ told HDC:

‘It is not appropriate to assess a patient for suitability for LTOT during, and in the 6 weeks following, a period of acute reversible decompensation.[56] [Mr A] was hospitalized with heart failure on a background of [COPD] and developed a hospital-acquired pneumonia. An evaluation for LTOT was necessarily deferred, as [national] guidelines require.’

77. However, Health NZ stated that Mr A should have been assessed for Short Term Oxygen Therapy (STOT),[57] to be provided at discharge for six weeks, which is ‘the standard of care for a patient who cannot be successfully weaned completely from oxygen but who is otherwise suitable for discharge’. Health NZ told HDC that in that case, an inpatient referral to the respiratory clinical nurse specialist (CNS) for consideration of STOT would occur and, if there was doubt as to whether the patient met the criteria for STOT, then consultant respiratory input would be sought.
78. Health NZ told HDC that a respiratory consultation was not obtained because the ‘predominant reason for Mr A’s admission(s) was heart failure’ and as Mr A had ‘recently’ been seen by Dr D, it was ‘incorrectly assumed’ that O₂ had been prescribed by Dr D, that Mr A and his wife were familiar with how to use it, and that therefore he had met the requirements for continuing STOT at the time of discharge.
79. Health NZ stated that the medical team, including Dr E, were unaware that Mr A had an ‘ozone machine’ and ‘were working on the mistaken belief that Mr A was using supplemental oxygen (consistent with STOT capability) at home prior to admission’, with ‘private oversight for its use’. Health NZ told HDC that ‘[t]his was the context for the team’s decision making through the period of the admission and on discharge’ and, had they known Mr A had an ‘ozone machine’, ‘this would have prompted an immediate investigation into what the machine was and how he was using it’, and he would have been referred for inpatient specialist respiratory input.
80. Furthermore, Health NZ told HDC that as Mr A was ‘relatively recently’ under the care of Dr D, ‘[f]ollow-up for [Mr A’s] optimization and education of respiratory care was believed to be occurring in the private sector, following his scheduled outpatient tests’.
81. Health NZ said that on reflection, it should have fully investigated Mr A’s oxygen provision prior to his discharge. Health NZ stated:

‘In hindsight the team should have clarified with [Mr A] and his family exactly what he meant when he confirmed he was on home oxygen therapy, who had prescribed it, and what the arrangements were in place for oversight of its continuing use. The team should have sought more information and clarity about his treatment plan from [Dr D] beyond the correspondence emailed through on 10 [Month6] to the team House Officer. This would have undoubtedly led to a formal assessment of oxygen needs and STOT being formally initiated at discharge.’

82. Health NZ told HDC that the survival rate of patients with cor pulmonale and COPD ‘is estimated at only 30% at 5 years’ and Mr A was ‘close to three years’ post-diagnosis when he was admitted on 8 Month6. Health NZ stated that Mr A’s condition was therefore viewed as ‘pre-terminal with no meaningful therapies that would change that situation’, so treating the acute decompensation and returning him home with symptom-based care ‘was a reasonable approach in that context’. However, Health NZ noted:

‘[I]t is clear from the family’s comments and distress when [Mr A] was readmitted in extremis on 19 [Month6] that they did not share the same understanding of [Mr A’s] bleak longer-term prognosis or treatment pathway. There was a missed opportunity to bring all parties to a shared understanding.’

Responses to provisional opinion

The complainants

83. The complainants were given an opportunity to respond to the information gathered during this investigation but had nothing further to add.

Health NZ

84. Health NZ was given the opportunity to respond to the provisional opinion. Health NZ accepted the ‘breach recommendation’ and had nothing further to add.

Relevant policies and standards

85. Health NZ Waitematā’s ‘Resuscitation Status Discussion with Patients/Families’ policy (2018) provides the following:

‘3. Medically Inappropriate CPR

Patients do not have the right to treatment when the likelihood of survival is so small that it would be regarded as medically inappropriate in the context of the patient’s condition.

Where cardiac arrest response is deemed to be an inappropriate procedure by the medical staff, it is senior medical staff responsibility to determine the information provided to each patient, (and/or family/whānau if the patient has diminished incompetence) and other members of the clinical team.’

Opinion: Health NZ Waitematā — breach

Introduction

86. This opinion discusses the care provided to Mr A by Health NZ Waitematā in Month6. In particular, it considers the adequacy of discharge planning and appropriateness of discharge.
87. It is clear from the information gathered that Mr A was a much-loved husband and father, who had a very unfortunate and extensive medical history. It is also evident that the complainants were very dedicated to Mr A, and I acknowledge the distressing impact his passing has had on them.
88. I have undertaken a thorough assessment of the information gathered in light of the complainants’ concerns. In my assessment of this complaint, I have considered information from the complainants, Health NZ, and RN C, as well as from the Office of the Coroner.
89. At the outset, it is necessary to acknowledge that there were clear misunderstandings about Mr A’s O₂ use at home, which appear to have influenced the care provided. To help determine whether the care provided to Mr A by Health NZ in Month6 was of an appropriate standard, I sought independent clinical advice from an internal medicine specialist, Dr Richard Shepherd.

Discharge planning

Assessment of O₂ prior to discharge

90. Health NZ stated that a formal assessment of Mr A’s need for O₂ prior to discharge, including review of his O₂ prescription and the ability to manage at home, was not undertaken.
91. Dr Shepherd advised that overall, in light of the ‘fragmented care between private and public, the stated misunderstandings around communication at the time decisions were made and the uncertainty around documentation available’, failing to formally assess Mr A’s need for home O₂, including review of his O₂ prescriptions and ability to manage at home, was a moderate departure from the accepted standard of care.

Assessment of O₂ availability at home, including ability to manage

92. It is recorded in the clinical notes that Mr A reported using O₂ at home and having seen a private respiratory specialist, Dr D, whose clinic letter was obtained by Health NZ on 10 Month6.
93. The complainants told HDC that although they purchased a natural ozone concentrator online for Mr A, which he used daily when he was getting short of breath, they repeatedly told staff that he did not have O₂ at home.
94. Health NZ told HDC that staff were unaware that Mr A was using an ‘ozone machine’, but rather ‘incorrectly assumed’ that because Mr A had ‘recently’ been seen privately by a respiratory specialist, Dr D, O₂ had been prescribed by Dr D and was consistent with STOT capability. Health NZ stated that ‘[t]his was the context for the team’s decision making through the period of the admission and on discharge’. Health NZ accepted that it should have investigated Mr A’s oxygen provision fully prior to his discharge.
95. Dr Shepherd advised that the issues around Mr A’s O₂ availability at home are ‘materially very important and woven into any assessment around his “ability to manage” — and ultimately how stable he might be expected to be at home’.
96. Dr Shepherd advised that given Mr A’s circumstances and diagnoses (in particular, his severe COPD, cor pulmonale and severe pulmonary hypertension), home O₂ use was indicated on his discharge ‘for a prognostic survival benefit [and] symptomatic benefit’. He said that this was particularly so, given that Mr A was rarely off oxygen during his 10-day hospital admission and potentially would have been expected to decompensate if O₂ was not available at home.
97. Dr Shepherd advised that there is no documentation that Mr A’s O₂ availability at home was assessed, ‘with “assumption” around his oxygen prescription acknowledged by [Health NZ] as the care that was provided’.
98. Dr Shepherd said that although Mr A was documented as having O₂ at home, there is very limited documentation of an adequate history around his oxygen use — in particular, O₂ prescription recommendations (target saturations), the oxygen source (ie, concentrator, bottled oxygen for ambulatory use), how the oxygen was obtained/its delivery method, or specific discharge advice around its use. Dr Shepherd advised that this was a ‘significantly overlooked aspect of [Mr A’s] care’ and, given the ‘potential prognostic benefit and therefore significant influence oxygen may have had on his appropriate treatment’, the lack of assessment was a departure from the expected standard of care.
99. I accept Dr Shepherd’s advice and am critical that Health NZ failed to assess Mr A’s O₂ availability and use at home adequately (and therefore his ability to manage at home), especially when weighing the potential prognostic benefit that this would have had, against the potential to decompensate if home O₂ was not available (given that Mr A was rarely off O₂ during his admission).
100. I acknowledge Health NZ’s admission that it should have investigated Mr A’s O₂ provision fully prior to discharge and, in my view, there were several points at which critical thinking about Mr A’s home O₂ use would have been appropriate — in particular, when there was confusion about Mr A’s reported O₂ saturation targets at home (discussed further below); that Dr D (who was presumed to have prescribed Mr A home O₂) had documented in the clinic letter that he ‘may be a candidate for portable oxygen’ based on the results of tests that had yet to occur, and Dr D had not documented that O₂ had in fact been prescribed; and when family raised concerns with staff about O₂ use at home. I am therefore critical that at the time, further investigations were not undertaken, but rather incorrect assumptions were relied on as the standard of care.

Formal assessment of home O₂ and inpatient respiratory input

101. Mr A did not receive inpatient respiratory input or a formal assessment for STOT or LTOT during his admission.
102. Health NZ stated that a respiratory consultation was not obtained, as Mr A’s primary reason for admission was heart failure, and, due to ‘mistaken belief[s]’, an assessment for STOT was not obtained as it was thought that Mr A had STOT at home and follow-up for his respiratory care was occurring in the private sector. Health NZ stated that had it been known that Mr A was not on prescribed O₂ at home (but rather that he was using a self-bought oxygen concentrator), he would have been referred to the respiratory CNS, as in that instance, Mr A should have been assessed for STOT.
103. In addition, Health NZ told HDC that as Mr A was hospitalised with heart failure on a background of COPD, and he developed hospital-acquired pneumonia, ‘an evaluation for LTOT was necessarily deferred’, as it is not appropriate to assess a patient for LTOT during, and in the six weeks following, a period of acute reversible decompensation.
104. Dr Shepherd said that although inpatient involvement of the respiratory service is ‘perhaps a matter of individual clinician judgement’, the presence of several factors[58] may have led many clinicians to seek specialist respiratory input, and ‘not just for [Mr A’s] oxygen use’. Dr Shepherd advised that given that initially Mr A was for full treatment and resuscitation, rather than palliative care,[59] seeking an additional respiratory opinion ‘had little to lose and much to potentially add’.
105. Dr Shepherd agreed with Health NZ that Mr A should have been assessed for STOT, but ‘struggle[d] to rationalise’ the justification for deferring an assessment of O₂. Dr Shepherd stated:

‘The available clinical notes at the time decisions were made in my view do not support any sense that oxygen evaluations were “necessarily deferred in [Mr A’s] case”. In my view they were simply not adequately reviewed or investigated and as a result the acknowledged inadequate treatment resulted.’

106. Dr Shepherd advised that ‘[t]he basis for not providing adequate care’ could be ‘inferred’ from the belief that follow-up of Mr A’s care was believed to be occurring in the private sector, which ‘perhaps underlies the recurrent absence of attention to the detail in this case and the accepting of the most superficial of “beliefs” without investigating further’.
107. In addition, Dr Shepherd noted that Dr D’s clinic letter raised a significant number of specialist respiratory issues with numerous investigations suggested. He advised that there was no consideration of these or further evaluation of the correct status of Mr A’s O₂ use. Dr Shepherd said that while the suggested investigations may not have been indicated when Mr A was acutely medically unwell, these were ‘important aspects of [Mr A’s] care, prognosis and management’ and ‘would have materially influenced the care he received’.
108. Based on the statements of Health NZ and the advice of Dr Shepherd, I accept that Mr A should have been discharged with home O₂, and that an assessment for home O₂ ought to have occurred prior to his discharge. The reason for the decision not to seek a formal assessment was the mistaken belief that Mr A was already on home O₂.
109. However, my concern is that if any of the multiple clinicians involved in Mr A’s care had tested their belief (listened to his family) and investigated Mr A’s O₂ use at home further, the mistake could have been corrected. I accept Dr Shepherd’s advice that Health NZ should not have accepted ‘beliefs’, and I remain critical that further investigations did not occur.

Review of O₂ prescriptions (target saturations)

110. It is noted throughout the clinical notes that Mr A reported being on intermittent O₂ at home, using O₂ ‘3–4 x per day for SOB’, and that he reported his usual target saturations as 88–92%.
111. When Mr A was admitted to the general medicine ward on 9 Month6, his target saturations were 88–92%, with a preference for ‘closer to 92’, given his underlying COPD. Health NZ stated that patients with COPD who are hypoxic and not CO₂ retainers should have target saturations of 88–92%; Mr A’s ABGs showed that he was not a CO₂ retainer.
112. During Mr A’s inpatient stay, target saturations were changed on multiple occasions, with clinicians on the same day documenting different target saturations (as per paragraphs 36, 41 and 49–50). In addition, Mr A fluctuated between the use of regular nasal prongs and HFNP, and in the days prior to his discharge, staff were struggling to wean Mr A off HFNP, with desaturations noted. Health NZ stated that Mr A’s target saturations were based on clinical assessment at the time, although ‘not perfectly executed’.
113. Dr Shepherd agreed that the prescribing of oxygen did not meet the accepted standard. He said that there appeared to be ‘significant confusion’ around Mr A’s O₂ use at home, his target saturations, and his family’s understanding and knowledge about this. Dr Shepherd advised that Mr A’s target saturations were changed without ‘clear consultant-level direction of this aspect of his care’.
114. Dr Shepherd stated that Mr A appeared to be using an oxygen concentrator at home, a small portable O₂ concentrator machine that can supply short- or long-term oxygen, although he noted that this was purchased without specific medical advice around its use or indication. In addition, Dr Shepherd advised that although Mr A’s clinical notes document that he was using oxygen ‘3–4x per day for SOB’ at home, this was not in accordance with standard guidelines for his circumstances, and it was not documented whether ‘that incorrect use’ was addressed or rectified prior to his discharge.
115. Dr Shepherd noted that an assessment for any significant desaturation on exercise or activity was not performed, and he advised that the recurrent difficulties in weaning Mr A off HFNP should have prompted a more detailed review of his oxygen prescription, and, if this occurred, it was not documented or provided as specific instructions on his discharge.
116. I acknowledge Health NZ’s admission that the prescribing of Mr A’s target saturations was ‘not perfectly executed’, and I accept Dr Shepherd’s advice. While clinicians had documented that Mr A was not a CO₂ retainer based on his blood gas results, there appeared to be confusion regarding his target saturations. I am therefore critical that Mr A’s O₂ prescriptions were not reviewed with consultant-level direction, given the evident confusion surrounding target saturations and the recurrent difficulties in weaning Mr A off HFNP.
117. Furthermore, while I acknowledge that Mr A had a self-purchased O₂ concentrator at home and that Health NZ was not aware of this, I accept Dr Shepherd’s advice that how he was using the O₂ concentrator was incorrect for his circumstances, and I am critical that regardless of the source of his O₂, this was not addressed or clarified with Mr A prior to his discharge. In my view, this deficiency in care fell outside of communication issues alone, although again I note that had there been adequate investigations into Mr A’s oxygen use at home, including his prescription and provider, this would have been relevant to any change of prescription on discharge home.

Conclusion

118. In summary, I find that Health NZ did not assess Mr A’s need for O₂ adequately prior to his discharge, for the following reasons:

1. Health NZ did not investigate Mr A’s O₂ availability at home, which resulted in a formal assessment for home O₂ not being undertaken; and
2. Health NZ did not review Mr A’s O₂ prescriptions, given the confusion surrounding target saturations, the difficulties in weaning Mr A off HFNP, and the incorrect use of Mr A’s home O₂.

Assessment of clinical stability prior to discharge

119. Mr A had a significant medical history and multiple competing comorbidities, which included recent hospital-acquired pneumonia, exacerbation of COPD, a type 2 myocardial infarction, IHD, exacerbation of heart failure/cor pulmonale, severe pulmonary hypertension, and chronic renal impairment with a recent AKI. He was on multiple medications to balance these conditions. In addition, on multiple occasions during his admission he was noted to be bradycardic, hypotensive, and hypoxic.
120. Dr Shepherd advised that in Mr A’s situation, the presence of severe competing comorbidities created a ‘prognostically, inherently unstable, clinical scenario’, and therefore ‘[a]nticipating significant “clinical stability” in such circumstances would be a very exact science and subject to much “benefit of hindsight” criticism if a discharge “failed”’.
121. Dr Shepherd advised that on the one hand, there was evidence of physiological instability over the 2–3 days prior to discharge, together with a number of changing circumstances — in particular, worsening renal function after earlier improvement; IV fluids for low BP the day before discharge; ongoing CCOT consultation; ceasing the ISMN medication the day of discharge (due to low BP); and weaning off HFNP to standard nasal prongs the evening before discharge, with limited time to assess for stability. Dr Shepherd advised that ‘[u]nder such circumstances, clinical stability could not be said to have been present’.
122. However, Dr Shepherd advised that ‘[w]eighing on the other side of that equation’, medical assessment on the day of discharge documented stability of Mr A’s observations, including HR, BP, and SpO₂ levels, that he was mobilising well, with no complaints or concerns raised overnight, and no respiratory distress noted. In addition, Dr Shepherd advised that there was evidence of ‘a “weaning” of care requirements’, such as the move from IV to oral antibiotics and attempted weaning of HFNP, and discharge goals (as outlined in paragraph 43). Furthermore, Mr A was ‘[k]een to go home’, and Dr Shepherd advised that the patient’s enthusiasm and readiness for discharge, ‘particularly in the setting of chronic severe health conditions and pre-existing functional impairment’, forms a ‘major component’ of that assessment.
123. Dr Shepherd advised that given Mr A’s significant comorbidities, ‘his already long duration admission with yoyoing “stability”’, and his clearly expressed wish to go home, he would regard this as only a mild departure from the expected standard of assessment of stability.
124. I accept this advice. However, while I appreciate that assessment of clinical stability would have been challenging in the context of significant cardiovascular comorbidity, advancing age, and respiratory disease, with the potential to deteriorate suddenly, I am concerned that the evidence of ongoing physiological instability (in particular, the difficulty weaning Mr A off high-flow O₂, his worsening renal function, and low BP) was not considered further when assessing Mr A’s clinical stability prior to discharge.

Review of medications prior to discharge

125. On admission, Mr A was diagnosed with AKI, which worsened during his inpatient stay. He was also noted to be bradycardic and hypotensive on multiple occasions. Mr A was treated with various medications to balance his diagnoses, including losartan and propranolol (which were regular medications for him and continued on discharge).
126. Health NZ acknowledged that there was an opportunity to review his medications in the pre-discharge period, in light of his hypotension, and stated that it would have been appropriate to ‘more proactively’ manage the combination of his propranolol and losartan medications prior to discharge.
127. Dr Shepherd commented on the appropriateness of continuing Mr A’s propranolol and losartan use at discharge. He advised that propranolol is a recognised contraindication in the setting of asthma or COPD, which was noted in Dr D’s clinic letter, and Dr D suggested reducing Mr A’s propranolol as this was likely exacerbating his breathing difficulties (as per paragraph 12). Dr Shepherd advised that the propranolol was ‘potentially contributing’ to Mr A’s recurrent hypotension, bradycardia, and worsening renal function, and, in addition, the losartan (prescribed in a high dose) was potentially ‘further contributing to his deteriorating renal function’.
128. I accept Dr Shepherd’s advice and am concerned that the use of propranolol and losartan were not reviewed by Health NZ, considering the adverse effects these medications were having on him. Although Dr D’s suggestion to reduce Mr A’s propranolol was noted by a GMHO on review of Dr D’s clinic letter (as per paragraph 28), it does not appear to have been considered adequately. In addition, while I acknowledge that losartan was withheld during the inpatient admission due to Mr A’s AKI (as per paragraph 37), I also note that it was to be continued on his discharge.
129. I acknowledge Health NZ’s admission that it would have been appropriate to manage the combination of Mr A’s propranolol and losartan medications proactively prior to his discharge. I remind Health NZ of the importance of taking every opportunity to review the continuation of medications adequately when adverse effects arise.

Conclusion

130. In my view, the adequacy of discharge planning in relation to Mr A’s need for home O₂ fell short of the accepted standard of care.
131. While I acknowledge that Mr A’s significant medical history and multiple competing comorbidities made discharge planning around his clinical stability challenging, I consider that given his circumstances, he should have been discharged with home O₂.
132. I am critical that rather than investigating Mr A’s home O₂ availability further, Health NZ relied on incorrect assumptions, which resulted in an inadequate assessment of his need for home O₂ prior to discharge. In addition, I am concerned that a review of his medications was not undertaken prior to discharge, despite the adverse effects these were having on him.

Decision to discharge

133. Health NZ stated that the decision to discharge Mr A on 18 Month6 was based on clinical improvement and stability, balanced with his desire to go home. In addition, Health NZ told HDC that ‘the context for the team’s decision making through the period of the admission and on discharge’ was that they were ‘working on the mistaken belief’ that Mr A had been prescribed home O₂, consistent with STOT capability, by Dr D, and therefore he had met the requirements for continuing STOT at the time of discharge.
134. Dr Shepherd advised that it was not appropriate to have discharged Mr A on 18 Month6, and I accept this advice.
135. In this instance, the culmination of omissions and inadequacies of Mr A’s planning, particularly surrounding his O₂ availability at home, meant that the decision to discharge him was inappropriate. While I remain critical that further investigations into Mr A’s need for O₂, and in particular his O₂ availability at home, were not undertaken, I acknowledge that Mr A’s inappropriate discharge was a consequence of the incorrect assumptions and miscommunications that occurred, rather than a separate failure by Health NZ.

Discharge advice

136. Mr A’s discharge summary did not document any specific recommendations around GP review or discharge advice regarding O₂ use at home and noted that no general medical follow-up was needed, although clinical notes document that ‘[r]return advice’ was given.
137. Health NZ told HDC that the plan for GP review post-discharge was not explicitly outlined in the discharge summary (as it should have been) and, as staff ‘were working on the mistaken belief’ that Dr D had prescribed Mr A home O₂, consistent with STOT capability, it was ‘incorrectly assumed’ that Mr A and his wife were familiar with how to use it, and that follow-up for his ‘optimization and education of respiratory care’ would be occurring in the private sector following his scheduled outpatient tests.
138. Health NZ stated that the expected discharge advice regarding Mr A’s O₂ use at home ‘was dependent on what he was already on, and what he had been advised to do by [Dr D]’, although it acknowledged that in hindsight, this had not been established clearly. Dr Shepherd considered this to be ‘an optimistic view of [Mr A’s] management circumstances’ and advised that the adequacy of information provided to Mr A on discharge regarding the use of O₂ fell short of the accepted standard of care.
139. Dr Shepherd advised that as O₂ is regarded as a medical therapy/intervention and drug, it would be expected that O₂ would be stated clearly on the discharge summary, including advice around its use. As noted by Dr Shepherd in paragraph 98, there was limited specific discharge advice around Mr A’s O₂ use.
140. In addition, Dr Shepherd considered it ‘unusual’ that no specific recommendations around timely review in a GP setting or general medical follow-up were made, given Mr A’s ‘long, complex and unstable admission where early medical review was likely to be anticipated’. However, Dr Shepherd acknowledged the challenges in accessing GP services during the holiday period and stated that this ‘may have confounded the usual post-discharge GP follow-up advice’.
141. I accept Dr Shepherd’s advice and, while I acknowledge Health NZ’s admission that the plan for timely GP review post-discharge should have been advised, as well as the limited access to GP services over the holiday period, I am concerned that neither a recommendation for GP review nor general medical follow-up was made, given Mr A’s unstable admission and complex medical history.
142. Furthermore, while I acknowledge that Health NZ had incorrectly assumed that follow-up for Mr A’s optimisation and education of respiratory care was occurring in the private sector, and that Mr A did not, in fact, have prescribed O₂ at home, I consider that this does not negate Health NZ’s duty of care to provide appropriate discharge advice, particularly on Mr A’s recommended target saturations. Given that ‘one of the crucial parameters’ that led to Mr A being cleared for discharge was meeting a target saturation that could ‘realistically’ be achieved at home (as per paragraph 55), these target saturations should have been documented.

Conclusion

143. Health NZ Waitematā is responsible for the operation of the clinical services it provides and has an organisational duty to provide an appropriate standard of care to consumers of its services.
144. Overall, as outlined above, there were significant issues with the care Mr A received at Health NZ. In particular:

• Health NZ failed to investigate Mr A’s home O₂ availability, which resulted in an inadequate assessment of his need for home O₂ prior to discharge.
• Given the evidence of ongoing physiological instability, the assessment of Mr A’s clinical stability prior to discharge was inadequate.
• Health NZ failed to review Mr A’s regular medications appropriately, despite the adverse effects these were having on him.

• Given the culmination of omissions and inadequacies of Mr A’s planning, it was not appropriate to have discharged Mr A on 18 Month6; and
• Health NZ failed to provide appropriate discharge advice, particularly Mr A’s recommended target saturations.

145. I acknowledge the stated miscommunication and incorrect assumptions made by Health NZ surrounding Mr A’s O₂ use, which affected the decision-making around his discharge from hospital. However, I remain of the view that the failure to investigate further and test these assumptions was unacceptable, particularly for a patient such as Mr A, who was reliant on O₂ being available and prescribed and administered correctly on his return home.
146. Accordingly, I find that Health NZ Waitematā did not provide Mr A services with reasonable care and skill, and therefore breached Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code).[60]

Resuscitation — educational comment

147. Mr A was re-admitted to hospital on 19 Month6, with right heart failure, severe pulmonary hypotension, and worsening AKI. After attempted treatment, the general medical team agreed that Mr A was ‘currently at [the] ceiling of care’, and his resuscitation status was changed to ‘not for CPR’/NFR, on a ‘Medically Inappropriate CPR’ basis.
148. The ICU registrar met with the family to discuss Mr A’s ‘not for CPR’/NFR status and it is documented that the family understood this, although Health NZ told HDC that it is not recorded whether the ‘concept’ of CPR was discussed specifically or whether it was confirmed that the family fully understood what NFR meant.
149. Mr A suffered a cardiac arrest; however, Ms B voiced objection to the NFR status and therefore a 777 call was made. Health NZ told HDC that the 777 call was ‘likely’ made as Ms B ‘was distressed at the rapid turn of events and wanted CPR to commence’. Two rounds of CPR were performed, but Mr A remained in asystole, and it was decided that ‘prolonged CPR was not in [Mr A’s] interest’ and CPR was stopped.
150. Regarding resuscitation decisions and discussions, Dr Shepherd acknowledged that ‘this can be a challenging area’. He advised that as Mr A was not for resuscitation on grounds that it would be medically inappropriate, his resuscitation proceeded against Health NZ Waitematā’s resuscitation policy (outlined in paragraph 85). Despite the ICU registrar documenting that Mr A’s family ‘understood [his] situation and that he would remain at ward-level ceiling of care’, Health NZ acknowledged that it is clear from the family’s comments (including questions asked by family during the discussion about CPR) that they did not share the same understanding of Mr A’s longer-term prognosis or treatment pathway. Dr Shephard considered that this could have been performed to a higher standard, and that this ‘may have contributed significantly to the distress associated with [Mr A’s] care’ for his family, staff, and ‘ultimately [Mr A] himself in the terminal phase of his life’.
151. I accept this advice and am mindful of the sensitivity of this topic in making the following comments.
152. As recognised by Health NZ, there was a missed opportunity to bring all parties to a shared understanding regarding Mr A’s condition. Although Dr E recalls telling Mr A that his medical issues were severe and irreversible (as per paragraph 34), I am concerned that the family were not made aware of his prognosis or his treatment pathway during his 10-day admission, which undoubtedly contributed to their distress on his readmission and resuscitation. Furthermore, while Mr A’s NFR status was discussed with the family, and it is documented that they were understanding of his situation, it is unclear whether the concept of CPR was discussed and whether they understood what NFR meant specifically. Had there been earlier and timely communication with Mr A’s family about his outlook, they may have been better prepared to understand and accept the decision that it was medically inappropriate to resuscitate.
153. Given Mr A’s circumstances and diagnoses, it was determined that he was at the ceiling of care. The ICU registrar explained that if Mr A were to be intubated and ventilated, he would never be able to come off a breathing machine, resulting in distress for him and the family. While I acknowledge and sympathise with Ms B’s distress at the unfortunate circumstances, and that her distress factored into Health NZ’s decision-making surrounding the commencement of CPR, I consider that when a clinician has determined that resuscitation is not medically appropriate, it should not be performed, and the views of family members are not binding.
154. I am therefore concerned that Health NZ Waitematā did not follow its resuscitation policy, and that CPR was performed, despite it being deemed medically inappropriate. I remind Health NZ of the importance of following resuscitation policies to ensure dignity to patients in their last stages of life, and of the need for timely, sensitive, and sufficiently clear discussion with family members regarding patient prognosis and treatment pathways.

Changes made since events

155. Since these events, Health NZ Waitematā has made, or is in the process of making, the following changes:

1. It has implemented the Health Quality and Safety Commission’s ‘Shared Goals of Care Programme’ (which has been formally released nationally), having initially piloted it in its medicine services between 2020 and 2021. The programme provides a valuable platform for discussions with family members, to bring all parties to a shared understanding of a patient’s prognosis or treatment pathway.
2. It is in discussion with the respiratory service as to whether an additional criterion for referral to the respiratory CNS service should be included for any patient admitted who informs Health NZ that they are on home O₂. Health NZ told HDC that there is nothing on the Electronic Discharge Summary to flag O₂ therapy, such as STOT, and consideration will be given to whether this could be added, potentially as a regional systems change.

Recommendations

156. I recommend that Health NZ Waitematā:

1. Provide a written apology to Mr A’s family for the deficiencies in care identified in this report. The apology is to be sent to HDC within three weeks of the date of this report, for forwarding to Mr A’s family.
2. Provide an update on the changes made outlined above — in particular, evidence of the implementation of the shared goals of care programme, and an update of referrals for respiratory CNS review of all inpatients who report using home O₂. This update is to be provided to HDC within six weeks of the date of this report.
3. Review the discharge policy and documentation to ensure that all discharges are well planned. Consider using a document where all staff can record discharge concerns (identified by staff or patients and whānau) that need to be addressed and resolved by the discharging team as part of the discharge process, ie, specialist reviews; medication review; oxygen prescription review on discharge; and ensuring that required equipment and prescribed oxygen are available on return home. Health NZ is to report to HDC on the changes made to its discharge policy and documentation.
4. Audit the discharge documentation of 20 medical patients (over the last six months) who were identified as using home O₂ and report on how many of those patients were given explicit written oxygen instructions at the time of discharge. If 100% audit compliance was not obtained, please provide a report to HDC on how performance will be improved in future.
5. Use this case as a basis for developing education/training on the importance of critical thinking during discharge planning. Evidence confirming the content of the education/training in the form of training material, and delivery in the form of attendance records, is to be provided to HDC.
6. Review the education/training being provided to staff in relation to communication of medically inappropriate CPR decisions and resolution of differences of opinion (including the option of seeking a second opinion). Evidence of the education/training having occurred, in the form of training material and staff attendance, is to be provided to HDC.

157. Recommendations c) to f) are to be provided to HDC within six months of the date of this report.

Follow-up actions

158. A copy of this report with details identifying the parties removed, except Health New Zealand|Te Whatu Ora, Health NZ Waitematā, North Shore Hospital, and the independent clinical advisor, will be sent to Health New Zealand|Te Whatu Ora, MedSafe, the Health Quality & Safety Commission|Te Tāhū Hauora, HealthCERT, and the Royal Australasian College of Physicians, and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.