Names have been removed (except Te Whatu Ora Tairāwhiti, Gisborne Hospital and the advisors) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

A Decision by the Deputy Health and Disability Commissioner

 

Introduction

How matter arose

Opinion: Te Whatu Ora — breach

Opinion: RN B — breach

Opinion: Dr C — adverse comment

Changes made since events

Recommendations

Follow-up actions

Appendix A: Independent clinical advice to Commissioner

Appendix B: Independent clinical advice to Commissioner

 

Introduction

1.               This report is the opinion of Carolyn Cooper, Deputy Health and Disability Commissioner, and is made in accordance with the power delegated to her by the Commissioner.

2.               The report discusses the postoperative care provided to Mr A by Te Whatu Ora Tairāwhiti (formerly Tairāwhiti District Health Board[1]) (Te Whatu Ora), following emergency surgery for a small bowel obstruction.[2]

3.               Mr A was in a stable condition immediately following the surgery, but his condition deteriorated overnight and, sadly, he died from a cardiopulmonary arrest[3] due to atrial fibrillation[4] on the day following the surgery.

4.               The matter was referred to the Health and Disability Commissioner by the Coroner.

5.               The following issues were identified for investigation:

·        Whether Te Whatu Ora│Health New Zealand provided Mr A with an appropriate standard of care in 2020.

·        Whether Registered Nurse (RN) B provided Mr A with an appropriate standard of care in 2020.

6.               The parties directly involved in the investigation were:

Mr A                                                                      Consumer

RN B                                                                      Registered nurse

Dr C                                                                       House officer 

7.               Further information was provided by:

RN E                                                                      Registered nurse

RN G                                                                      Registered nurse

8.               Parties also mentioned in this report:

Dr D                                                                       General surgeon

Dr F                                                                       House officer

How matter arose

Medical history

9.               Mr A’s medical history included high blood pressure, a STEMI[5] heart attack, high cholesterol, and a stroke. Mr A also had right subclavian artery stenosis (a form of peripheral arterial disease that can result in different blood pressure measurements in each arm).

10.             Mr A had a history of recurrent small bowel obstruction secondary to radiation for prostate cancer and he  underwent bowel surgery (a laparotomy[6] and adhesiolysis[7]).

11.             Some of Mr A’s regular medications included metoprolol,[8] cilaprazil,[9] and simvastatin.[10]

Arrival at Emergency Department (ED)

12.             In 2020, on Day 1,[11] Mr A had a sudden onset of abdominal pain with associated nausea and vomiting. He was taken to the ED at Gisborne Hospital by ambulance and arrived at approximately 8.00pm.

13.             Upon arrival, Mr A had no chest pain but there was a significant difference between the blood pressure measurement in his right and his left arm.[12]

14.             Mr A was reviewed by an Emergency Medicine specialist, whose impression was one of small bowel obstruction. The Emergency Medicine specialist arranged blood tests and a CT[13] scan, which confirmed the diagnosis of small bowel obstruction. The Emergency Medicine specialist referred Mr A to the surgical team.

15.             At 10.10pm on Day 1, Mr A was admitted to the surgical ward by the on-call house officer, Dr C.

16.             Several of Mr A’s regular medications were withheld, including metoprolol.

17.             On the ward, Mr A’s abdominal pain and vomiting persisted. Mr A’s Early Warning Score[14] (EWS) was 4[15] but his condition continued to deteriorate and his EWS increased to 6.[16] Te Whatu Ora said that there is no evidence that Dr C, who was the on-call house officer, responded promptly when Mr A’s condition deteriorated and, as a result, the staff nurse made a rapid response call for Mr A to be reviewed.

18.             Mr A was seen by the rapid response team and by Dr D, a general surgeon, and a decision was made for Mr A to undergo surgery the following morning.  

Surgery

19.             At 9.00am on Day 2, Mr A underwent an emergency laparotomy and a small bowel resection.[17] The surgery was performed by Dr D. The surgery was uneventful and immediately following the surgery Mr A was in a stable condition.

Transfer to ICU

Day 2

20.             During and following the surgery, Mr A’s blood pressure was monitored with an arterial line.[18] At 1.15pm on Day 2, following the surgery, Mr A was transferred to the Intensive Care Unit (ICU), in accordance with the postoperative instructions. The postoperative instructions included a plan for monitoring Mr A’s average arterial blood pressure[19] and a recommendation for management of low blood pressure with a noradrenaline infusion,[20] if required. Care of Mr A was handed over from the recovery nurse to RN E.

21.             RN E said that she completed a ‘head to toe’ assessment of Mr A, and she ‘checked and zeroed’ Mr A’s arterial line. RN E completed two full sets of EWS calculations. RN E documented in the clinical records that there were ‘[n]il concerns’. RN E told HDC:

‘After ascertaining the condition of [Mr A] I was able to document his observations and condition, while outlining his management plan and confirming the acceptable parameters for his observations. As is gold standard and common practice within ICU/CCU I noted his blood pressure measurements from his arterial line as it was transducing well and had an acceptable waveform, and documented this in his clinical progress notes. [Mr A] was only in my care for around two hours, and during this time he was stable and there was no indication that he was deteriorating in any way, or that he needed any type of urgent review by a Doctor.’

22.             At approximately 3.00pm, care of Mr A was handed over to RN G.

23.             Between 3.30pm and 4.00pm, Mr A was reported to be comfortable, and his abdominal pain was ‘almost gone’. Mr A’s blood pressure[21] and heart rate[22] were stable, and he had an EWS of 2[23] due to supplemental oxygen.

24.             At 9.40pm on Day 2, RN G noted a T-wave inversion[24] on Mr A’s telemetry.[25] RN G performed an electrocardiogram[26] (ECG), which showed signs of possible myocardial ischaemia.[27]

25.             RN G notified the on-call house officer, who at that time was Dr F.

26.             Dr F reviewed Mr A at 9.45pm. Dr F noted that Mr A had ongoing abdominal pain, but no chest pain or shortness of breath. Dr F noted that Mr A appeared euvolaemic.[28]

27.             Dr F’s plan was for Mr A’s troponin[29] levels to be reviewed within two hours (at 11.45pm). Dr F documented, ‘not for any intervention at this stage’, and to monitor Mr A’s blood pressure, heart rate, oxygen saturation, and chest pain. Dr F directed the nursing staff to page the on-call house officer if there was any change in Mr A’s condition.

28.             RN G said that Mr A remained stable throughout her shift, and she used the arterial line to measure Mr A’s blood pressure. RN G stated: ‘[Mr A’s] blood pressure did not drop on my shift. Nor did I have any issues with the A-Line, or with blood pressure generally, on this shift.’

29.             Dr C was the on-call house officer on the evening of Day 2, and his shift started at 10.00pm. Dr C stated that upon commencing his duty, he received a handover from Dr F in the ICU office at approximately 10.15pm.

30.             Dr C said that Dr F informed him of Mr A’s surgery, ‘and reported that there were no active issues with [Mr A]’. Dr C stated that he recalls asking one of the two ICU nurses (he cannot recall which nurse) whether they had any concerns about Mr A and was told that they had none.

31.             At 11.15pm, RN G paged the on-call house officer to ask whether Mr A could be administered metoprolol orally, as Mr A was Nil by Mouth and his other oral medications had been withheld. There is nothing in the clinical records to indicate what instructions were provided by the house officer, if any, in relation to whether Mr A could be administered metoprolol. RN G did not administer Mr A with metoprolol as her shift ended at 11.15pm, and care of Mr A was handed over to RN B for the night shift. RN G said that she would have covered this in her handover to RN B at the end of the shift.

32.             RN B did not make any entries in the clinical records from the time she took over care of Mr A at approximately 11pm until 3.55am on Day 3. RN B documented the care retrospectively at 3.55am on Day 3. From 3.55am to 7.00am on Day 3, there are no nursing entries in relation to the administration of metoprolol, the assessment of its effect on Mr A, or Mr A’s condition.

33.             RN B documented that at 11.00pm, Mr A had ‘confused verbalisation’ and ‘doesn’t follow commands’. RN B noted: ‘[On-call house officer] knows [patient] from admission [and reviewed patient] = [no new orders].’

34.             RN B and Dr C presented differing accounts of the events that followed.

35.             RN B stated that at the time of her assessment of Mr A at 11.00pm, she noted a disparity between the arterial line blood pressure and the non-invasive[30] blood pressure.[31] Initially, RN B said that she discussed this with Dr C, but subsequently, she said that she discussed this with Dr F, and not with Dr C. Initially, RN B stated that she recalls asking Dr C ‘what could be going on?’ in relation to Mr A’s blood pressure. RN B said that ‘a discussion ensued whereby Dr C drew a diagram to explain the findings, a diagnosis of R) subclavian stenosis known for [Mr A]’. In response to the provisional opinion, RN B said that this discussion was with Dr F, and that it was Dr F who had drawn the diagram, not Dr C.  RN B said:

‘I absolutely went into the office and asked the House Surgeon — [Dr F] who was on the unit making decisions regarding the infarction — why is there this discrepancy? [Dr F] drew a picture for me on the office notepad in front of the computer explaining the mechanisms in effect. I specifically asked — well which blood pressure measurement is the relevant one to use in determining his vascular pressure? The reply was to use Left arm pressures — which is exactly what I did. The comments made by the surgical team that I “ignored” [Mr A’s] arterial [blood pressure] measurement is pejorative and untrue. I was trying to do the best for my patient guided by medical advice … On reflection I could have recorded both, but I would still have been left with the impression that the left blood pressure was the more accurate/influential pressure to be mindful of.’

36.             Dr C said that RN B did not discuss a disparity between the arterial blood pressure and the non-invasive blood pressure with him at around 11.00pm. Dr C also said that he did not receive a page from RN G at 11.15pm, and he was not informed of Mr A’s ‘confused verbalisation’, or inability to follow commands. Dr C said that he was not made aware of any concerns in relation to Mr A on Day 2. Dr C said that the first time he was made aware of any concerns was shortly after 3.00am on Day 3, when Mr A had gone into atrial fibrillation (discussed further below).

37.             At 11.40pm, in accordance with Dr F’s plan, RN B reviewed Mr A’s troponin levels, which were elevated.[32] It is unclear from the clinical records what actions, if any, RN B took in response to Mr A’s elevated troponin levels at this stage. Dr C said that he received no handover regarding following up on Mr A’s troponin levels.

Day 3

38.             From around midnight, Mr A’s blood pressure started to drop progressively,[33] and his heart rate increased.[34] At this point, Mr A’s urine output decreased,[35] and his GCS[36] score decreased from 15/15 to 13/15. RN B documented that Mr A’s respiratory rate was 24 breaths per minute, but she incorrectly documented this in the row on the EWS that scored 0 points, when it should have scored 2 points.

39.             Dr C said that at approximately 12.30am, he was asked to review another patient in ICU. Dr C stated:

‘As I was passing through ICU, I asked [RN B] whether there were any changes or concerns with [Mr A]. I was told there were no concerns or changes to report. I recall being quite rushed at this stage, and so did not follow up with any more specific questions than that.’

40.             At 1.00am, Mr A’s heart rate was elevated,[37] and his blood pressure remained low.[38] RN B documented that Mr A’s respiratory rate was 26 breaths per minute, but again, she incorrectly documented this in the row on the EWS that scored 0 points, when it should have scored 3 points.

41.             At 2.00am, Mr A’s heart rate had improved,[39] but his blood pressure remained low.[40] RN B documented that Mr A’s respiratory rate was 25 breaths per minute. This was also incorrectly documented on the EWS row that scored 0 points, when it should have scored 3 points.

42.             At 3.00am, RN B noted that Mr A’s heart rhythm[41] had changed to atrial fibrillation[42] (120–155bpm), with abnormalities on his ECG. RN B also documented that the arterial blood pressure was inconsistent with the non-invasive blood pressure. At this point, Mr A’s GCS score remained at 13/15. Mr A’s respiratory rate remained at 25 breaths per minute, which was again incorrectly documented on the EWS that scored 0 points, when it should have scored 3 points.

43.             RN B stated that it was not Mr A’s blood pressure in itself that was of concern, as it remained within acceptable parameters, but it was the clinical presentation in its totality, ‘noting the subtle changes in trends with [a decreasing] level of consciousness, [an increasing] heart rate, change in rhythm and fluid imbalances which [led] to concern’.

44.             RN B said that she recalls paging Dr C for assistance and discussing the situation with him over the phone, but that Dr C was in ED at the time and unable to review Mr A in person. RN B stated that ‘having the on-call [house officer] prioritise care elsewhere in the hospital was a regular occurrence on night duty’.

45.             Dr C confirmed that he was paged by ICU just after 3.00am. He stated:

‘At the time I was in the Emergency Department having a family meeting with a large family about end of life care for a patient. In addition I had four other patients waiting to be seen on four different wards, as well as four others waiting to be admitted in the ED.’

46.             Dr C said that he responded to the page shortly after 3.00am by calling RN B. Dr C stated:

‘[RN B] told me [Mr A] had gone into Atrial Fibrillation at 140–150 beats per minute. I asked what his blood pressure was and I was told it was 130/[70]. I was informed also that he had good urine output and had intravenous fluids running. I asked if he had received his usual Metoprolol (a beta-blocker which slows the heart rate) for his pre-existing Atrial Fibrillation. I was told that he had not. I suggested that his oral Metoprolol be resumed, but was told he had been unable to swallow since his operation. We discussed IV Metoprolol as an alternative. [RN B] thought IV Metoprolol was a reasonable plan. I was aware of her background working in a cardiac unit where Metoprolol is used frequently, and so I was reassured by her confidence. Accordingly, I gave a verbal order for a slow push of IV Metoprolol, 5mg.’

47.             Dr C said that the only information he received about Mr A’s low blood pressure and deteriorating condition during the night shift was shortly after 3.00am, when he responded to the ICU page, as discussed above.

48.             Dr C undertook no physical examination of Mr A during his night shift. Dr C stated that, apart from the atrial fibrillation, RN B did not report any other concerns about Mr A’s condition to him, and she did not ask him to review Mr A.

49.             Dr C said that after having spoken to RN B shortly after 3.00am, he did not consider that a physical review of Mr A was indicated, nor did he consider that the on-call surgical senior medical officer (SMO) needed to be called to discuss the case. Dr C stated:

‘At no stage was I asked to review [Mr A], and my workload was such that unless I had been told he had been deteriorating or asked to review him, I simply did not have the time to do so. Had I known more, in particular the steady deterioration of his blood pressure which the A-line demonstrated since 2300, I would have gone to review him in any event. However none of that information was conveyed to me.’

50.             Dr C said that he would have preferred to review Mr A before he prescribed metoprolol but said that he was aware that Mr A had previously been on metoprolol for his pre-existing atrial fibrillation. Dr C stated that he was reassured by the confidence expressed by RN B, as a senior ICU nurse, that the medication was appropriate. Dr C said that in the circumstances, he considered that his priority was to attend to the four other patients who were awaiting his review. Dr C said:

‘[RN B] did not ask me to review [Mr A] in person. Other than the atrial fibrillation, she raised no concerns, and made no mention of a deteriorating EWS. I felt reassured that [Mr A] was sufficiently stable, so that an immediate review was not indicated. In retrospect, I accept that this was a missed opportunity, and that given we were considering the administration of IV metoprolol, I should have undertaken a review or alternatively contacted the on-call SMO.’

51.             At 4.10am, Dr C confirmed his verbal order for Mr A to be administered intravenous (IV) metoprolol by initialling the medication chart, and the metoprolol was given at 4.10am.

52.             It is documented on the medication chart that metoprolol was to be administered ‘stat’. Dr C stated that this was not his instruction, and that he had asked for the metoprolol to be administered in a ‘slow push’, which meant ‘small increments of about 1mg with a minute between each push’. RN B said that the word ‘stat’ on the medication chart was intended to mean ‘give it now’ and was not intended to mean ‘just push in the drug/dosage’.

53.             Shortly after the metoprolol was administered, Mr A’s clinical condition deteriorated, and his blood pressure dropped further. A rapid response call was made, and Mr A was given adrenaline[43] and three cycles of CPR.[44]

54.             Dr C stated:

‘I heard nothing further until approximately 0430, when there was a rapid response call for ICU. When I got there shortly afterwards, the nursing staff were already performing CPR on [Mr A]. While CPR was going on, I called the on-call Surgical SMO. I got through on the second attempt, informed him of the situation, but was told that there was nothing he could do and I should call the on-call anaesthetic SMO. I got through to the anaesthetic SMO on the fifth attempt, and he came into the Hospital. [Mr A] was then intubated[45] and ventilated.[46]’

55.             The anaesthetist reviewed Mr A at 4.30am (during the rapid response call), noted that Mr A’s blood pressure had dropped and there was no carotid pulse,[47] and intubated and ventilated Mr A. At this point, Mr A’s whānau was contacted and informed of his condition.

56.             At 6.15am, following discussions with Mr A’s family, Dr C completed and signed a Medically Initiated ‘Not For Resuscitation’ Authorisation form, noting that he believed that resuscitation was not in Mr A’s best interests. The form notes that this was not discussed with Mr A, but that it was discussed with Mr A’s relatives. Care was withdrawn and Mr A died in the presence of his family at 7.00am.

57.             Te Whatu Ora told HDC:

‘It is unclear why [Dr C] did not respond in a timely manner when [Mr A’s] condition deteriorated. There were several calls made to [Dr C] on both night shifts. There was no bedside review of [Mr A] to ascertain the cause of his clinical deterioration and therefore prescribe appropriate treatment. [Dr C] also did not alert or seek assistance of [Dr D] or the Anaesthetist on call to help manage [Mr A], when his condition deteriorated. This only occurred once [Mr A] went into cardiac arrest. This is in contrast to [Dr F] who reviewed [Mr A] promptly when his clinical condition deteriorated.’

58.             Dr C told HDC:

‘It is not true that several calls about [Mr A] were made to me that night. I received the one page just after 0300, and at approximately 0430 I responded to the rapid response call. As I have said, when I spoke to [RN B] shortly after receiving the page, I was not asked to review [Mr A]. I accept that I should have done so anyway, or alternatively contacted the on-call SMO.’ 

EWS chart

59.             RN G calculated and documented the total scores on the EWS chart at 3.00pm, 4.00pm, 8.00pm, and 9.00pm on Day 2 (when Mr A’s EWS was 2), but she did not calculate and document the scores at 5.00pm, 6.00pm, or 7.00pm on Day 2.[48]

60.             RN G told HDC that she did not document these total scores because she did not check Mr A’s temperature at those times as he was not feverish. RN G said that if she had been concerned, she would have checked the EWS every hour as a matter of practice. RN G explained that to have an accurate EWS, all the observations on the EWS chart needed to be checked. RN G told HDC:

‘The HDU EWS charts were fairly new to ICU at this time. We had some in-service training in the ward about the EWS charts … In terms of escalating care, I follow the EWS chart or if I am concerned about a patient [I] will call text or page the appropriate medical officer to review depending on the situation.’

61.             RN B did not calculate and document any of the total scores on the EWS chart for her entire shift on Day 2 and Day 3.

62.             RN B said that she does not believe that the failure to total the scores on the EWS chart contributed to any delay in the escalation process ‘as concerns in the patient’s condition had been raised from the beginning of the shift’. She accepts that she did not calculate and document the total scores on the EWS chart. RN B stated:

‘[T]he EWS chart was a relatively new tool and having many years of critical care experience overlooked the practice of totalling, as having critical inquiry and thinking to determine actions is an inherent default.’

63.             The Director of Nursing told HDC:

 ‘Upon interview of the RNs involved, various other ICU RNs from the period in question and the Clinical Coach [who] held the portfolio for EWS rollout, the EWS chart is said to have been in its infancy as a newly introduced tool to ICU practice (approx 6-months old).’

64.             RN B stated: ‘[W]e are all adapted and used to EWS charts now, but certainly [we were] not during 2020.’ 

Staffing levels

65.             Dr C told HDC that as the house officer on the night shift, he was covering all the wards in the hospital, which included medicine, surgery, orthopaedics, maternity, paediatrics, and psychiatry.

66.             Dr C said that there was one Emergency Medicine SMO on duty, but the SMO’s duties were confined to the ED. Dr C told HDC: ‘I do not know how many in-patients we had that night, but I would guess it was more than fifty. I do know I was frantically busy, all night long.’

67.             Dr C said that prior to these events, there had been email communications between both the junior and senior doctors in the medical department about ‘how the workload at night was unmanageable and unsafe for just the one junior doctor’.

68.             Dr C said that in the year prior to the events, an audit had been undertaken, and it was his understanding that the audit had confirmed that ‘the workload at night was unmanageable’. Dr C stated: ‘Almost invariably whenever I was on night duty, I found myself virtually running from patient to patient all night long. I felt that the workload was unsafe.’

69.             Te Whatu Ora told HDC:

‘[RMOs[49]] have excellent access to their [SMOs] and are encouraged to contact them early if there are any concerns. The recent MCNZ review confirmed that junior doctors had good access to [SMOs] and felt confident that they could escalate concerns to them. There were a number of SMOs available to provide advice, including the Emergency Medicine Specialist, Physician on call, General Surgeon on call and the Anaesthetist on call.’

70.             Dr C disagrees with Te Whatu Ora’s assertion that RMOs had ‘excellent access’ to SMOs at the time of the events. Dr C said that on ‘many occasions’ when he contacted the on-call SMO after hours, either the phone would not be picked up, or the response would be ‘short and abrupt on account of the SMO having been awoken from sleep’. Dr C said that while it is true that the RMOs were encouraged to contact the SMOs early in the event of any concerns, in his experience, the reality was otherwise.

Guidelines, policies, and procedures

Admission and Patient Management in the ICU/HDU/CCU

71.             Te Whatu Ora’s guideline on Admission and Patient Management in the ICU/HDU[50]/CCU[51] (dated February 2018) (ICU Guideline) specifies the admission of patients to, and management in, the ICU, HDU and CCU, so that patients can be monitored more closely and receive appropriate treatment in a timely manner. The ICU Guideline provides clarity on the responsibilities for medical staff regarding the admission and management of patients within the ICU/HDU/CCU.

72.             The ICU Guideline states that the primary team consists of the consultant under which the patient is admitted to the ICU/HDU/CCU and the medical staff for whom the consultant is responsible.

73.             The ICU Guideline states that clinical care on a day-to-day basis is the responsibility of the primary team, but that most patients will benefit from a multidisciplinary team approach (anaesthetists, physicians, surgeons) of joint bedside management in a collegial supportive manner to deliver optimal care and outcomes. It states that this is the overarching principle of good ICU/HDU/CCU care.

74.             The ICU Guideline states that a primary team, requesting admission of a patient to ICU/HDC/CCU, accepts the following management principles:

‘·  Clinical management of the ICU/HDU/CCU patient should include two bedside patient reviews per day, conducted by the SMO team (Minimum Standards for Intensive Care Units, 2011) …

·   A request to review a patient at the bedside in ICU/HDU/CCU must be met by a member of the primary team (or the covering on-call team) promptly (<15 minutes) …’

75.             In relation to the role of different care teams, the ICU Guideline states:

‘·  Deteriorating patients need to be discussed with the SMO.

·   These patients will be identified to the RMO by the senior nurses on duty. The RMO will contact the SMO to discuss the patient.

·   In some circumstances the senior nurse on duty might escalate the process and contact the SMO directly …’

Adult vital signs and EWS

76.             Te Whatu Ora’s policy on Adult Vital Signs and EWS; Measurement, Recording and Escalation Pathway (dated January 2018) (EWS Policy) states that the policy does not include patients during their stay in ICU/CCU but that EWS will be documented on admission and discharge to ICU.

Prescribing of medication

77.             Te Whatu Ora’s Prescribing Policy states that controlled drugs[52] should not be ordered over the telephone, unless in exceptional circumstances. The Prescribing Policy states that only a single dose of a medicine, or enough to cover the 24-hour period until it can be signed by a prescriber, can be administered via a telephone call or verbal order.

78.             Te Whatu Ora told HDC that Dr C followed the Prescribing Policy. Te Whatu Ora said that RMOs are provided guidance on prescribing medications and that they are made aware of organisational policies.

79.             Te Whatu Ora stated:

‘It would not be usual practice for a clinician to give verbal orders for IV Metoprolol, without reviewing the patient. All [RMOs] are required to undertake the ACLS[53] course that provides a framework for managing cardiac arrhythmias. In a post-operative patient, it would be prudent to understand the aetiology of atrial fibrillation, as these need to be addressed along with the management of arrhythmia. [Dr C] would also have been aware that a number of [Mr A’s] antihypertensive and anticoagulants were withheld on admission the previous day.’

80.             Dr C told HDC that as far as he was aware, he received no training or education about verbal medication orders.

Dr D’s statement

81.             Following the events, Dr D provided a statement to the New Zealand Police[54] outlining his concerns about the care provided to Mr A.

82.             Dr D stated that following the surgery, Mr A was admitted to the ICU, but given Mr A’s age, ‘the recovery from surgery comes with some heightened complication factors’.

83.             Dr D said that on Day 3, the morning following the surgery, he was advised that Mr A’s condition had deteriorated, and that Mr A had died. Dr D stated that neither he nor his senior colleague had been contacted in relation to Mr A, since Mr A was in the care of the ICU.

84.             Dr D stated that a review of the events was undertaken by a clinician who ‘immediately had some concerns about the practices observed and documented’ in relation to Mr A’s postoperative care. Dr D’s statement to the Police included the following:

‘The first concern we had was in relation to blood pressure checks. There are two ways to ordinarily measure for blood pressure. The first is an indirect non-invasive measure using a blood pressure cuff. This is recognized as not a perfect system of measurement and there are variables to be considered such as the size of the actual cuff and other factors like any obstructions such as whether it’s over clothing, cords, arterial disease, etc.

The other way to measure blood pressure is via an invasive arterial line (A-line) which goes into a blood vessel on the wrist and gives a continuous up to date measurement of blood pressure. This method of testing blood pressure is considered a “Gold standard” measurement and is the most accurate in most incidences. We observed in the case summary that the nurse had adopted both ways to measure blood pressure.

The recordings documented show the A-line blood pressure measure dropping over a timeframe of several hours. However there was no action taken in response to this measurement reading dropping. The reading that they have based their ongoing treatment on is the reading on the blood pressure cuff which is typically less accurate than the A-line measurement. The cuff measurement was reading a higher blood pressure.

We also noted that they had not been using the EWS score which is an assessment tool used to tally up the patient’s vital signs and based on score it [instructs] actions to take when things are outside a normal range … This chart was not used accurately and the tallies were not added up so there was no prompt to consult with anyone.

Around the same time it was also noted that the patient’s electrocardiogram (ECG) was showing changes of lateral [ischaemia]. These are changes on the pattern of the heart’s pacing system that suggest the heart is straining and not receiving enough blood supply.

I also observed that there was no physical medical review completed for the patient by the House Officer (Junior Doctor on-duty).

Later on; and while the blood pressure continued dropping; the patient’s condition deteriorated further with him going into atrial fibrillation. This is a type of cardiac arrhythmia [where] the heart starts beating quite fast and can further affect the blood pressure. It also increases the amount of blood supply the heart requires.

The House Officer was once again contacted and despite no physical review a verbal prescription for a medicine (Metoprolol) was given over the phone. This medication would slow down the heart and also decrease the blood pressure.

My concern is that the medicine prescribed is not one that you can typically prescribe over the phone and certainly is not ordinarily prescribed without a physical review of the patient.

Based on all of these contributing factors I have concerns that the standard of care offered was not to the standard expected and should it have been at the standard expected and in line with the trained practices it may have prevented such a rapid deterioration of the patient’s status while he was in the hospital’s care and potentially even prevented the death of the patient …’

Te Whatu Ora’s review

85.             Following the events, the surgical team reviewed the care provided to Mr A at a Mortality and Morbidity meeting, and noted the following issues:

‘·  Nurse ignored A-line [blood pressure] despite good trace because [non-invasive blood pressure] higher.

·   No EWS score recorded.

·   No escalation of care or medical review over 12h until arrest.

·   IV metoprolol given as verbal order by [house officer] when patient went into [atrial fibrillation].

·   Tachycardia[55] and hypotension[56] post op = hypovolemia[57] until proven otherwise. No fluid bolus given or bloods repeated.’

86.             Te Whatu Ora held a rapid review meeting. Minutes of the meeting noted the following:

·     Mr A was high risk preoperatively due to his cardiac history and stroke in 2019. The minutes state that the ‘outcome of death may have been the same, however there was a lack of escalation which may have prevented [Mr A’s] death’.

·     The house officer was informed that Mr A was haemodynamically stable, and ‘was not given the full picture of the patient e.g the [blood pressure] dropping; and difference between the [A-line blood pressure] and cuff’.

·     The EWS chart score was not totalled ‘and if it was escalation would have resulted earlier’.

·     The decision-making did not involve the whole team, ie, nursing and medical.

87.             The minutes state: ‘[The] [e]scalation process needs to be looked at. Surgical team is more than happy to be phoned out of hours.’

Further information

Te Whatu Ora

88.             Te Whatu Ora expressed its sincere condolences to Mr A’s family on the passing of Mr A.

RN B

89.             RN B expressed her deepest condolences to Mr A’s family and said that she can understand their distress and concerns.

Dr C

90.             Dr C expressed his sincere condolences to Mr A’s family for their sad loss.

91.             Dr C told HDC:

‘On the basis of the clinical information conveyed to me at the time, and given the clinical workload and pressure I was under, I consider that the care I provided was to an appropriate standard, (recognising that,  save for the Emergency Department, I was the sole medical practitioner covering the Hospital that night).’

92.             Dr C said that he is deeply regretful that he did not review Mr A, but said that he considers that in the circumstances, it was reasonable for him not to do so.

Responses to provisional opinion

Mr A’s family

93.             Mr A’s family was given an opportunity to respond to the ‘Introduction’, ‘How matter arose’, and ‘Changes made since events’ sections of the provisional opinion.

94.             Mr A’s family said that they do not believe that the care provided to Mr A by Te Whatu Ora and RN B was to an acceptable standard. Mr A’s family said that, while they believe that Dr C had made mistakes, it is the family’s view that Dr C relied on RN B, who he believed to be an experienced nurse, and that he had been placed in an unenviable position by Te Whatu Ora. Mr A’s family said:

‘While accepting that [Mr A] had underlying health issues it is the family’s view that he may well have still been alive today had [RN B] and Te Whatu Ora provided an acceptable level of care.’

95.             Mr A’s family told HDC that they do not consider that Dr C should be held responsible for the events that occurred.  

RN B

96.             RN B was given an opportunity to respond to the sections of the provisional opinion that relate to the care she provided.

97.             RN B’s comments have been incorporated into this opinion where relevant and appropriate.

98.             RN B said that she remained at Mr A’s bedside constantly due to Mr A’s increasing confusion but given that there were only two registered nurses on duty overnight, they were required to leave patients’ bedsides to complete unit-specific tasks, such as fetching equipment and fetching medications from the treatment room. RN B said that post-anaesthetic confusion in elderly persons is not unusual but requires nursing management and care.  

99.             RN B said that in 2009, when she first started working in the ICU at Te Whatu Ora Tairāwhiti, it was common practice for the nursing staff to call the consultants directly, but in 2020 this was no longer the case. RN B said:

‘By 2020 this practice was long gone, we nurses had to consult with the house officers and then if the house officer considered it necessary, then they would call the consultant. This has been an ongoing issue for years, including anaesthetists who won’t speak to nurses unless the consultant calls them (the anaesthetist) directly when issues arise. In essence the consultants themselves initiated their “chain of command” and it didn’t involve nurses (except for calling the house surgeon first — there are now registrars too, but in 2020 I don’t think we had any). It Is quite disingenuous of the surgeons to say they are happy to be called anytime, when in practice they themselves dissuaded nurses from doing so … I certainly have a lot of sympathy for the pressures [Dr C] was under, however, it was his call to get help from his seniors or not — I was involved with caring for [Mr A] and was not [cognisant] of the impossible workload he had that night.’

100.          RN B apologised to Mr A’s family for her comment on the family’s arrival at the ICU when she stated that Mr A ‘had caused us a few issues last night’. RN B said:

‘I can’t apologise enough for my inappropriate comment. I can [realise] the circumstances of how and why I said that but that is meaningless to a distressed family. I’ve tried to think of how I would phrase my words if I could re-do that time and the best I can think of right now is “I’m sorry you’ve received the sudden news of your husband/dad’s condition. Is there anyone or anything you’d like right now to help” …  Once again I apologise and recognise my insensitivity here.’

Dr C

101.          Dr C was given an opportunity to respond to the sections of the provisional opinion that relate to the care he provided.

102.          Dr C’s comments have been incorporated into this opinion where relevant and appropriate.

103.          Dr C said that he accepts the following criticisms of his care, which are mitigated by the circumstances discussed in the provisional opinion:

·        That he did not escalate care of Mr A to the on-call SMO when he was unable to review Mr A at around 3.00am on Day 3;

·        That he did not undertake a bedside review of Mr A or ask the on-call SMO to review Mr A, if he was unable to do so, at around 3.00am on Day 3; and

·        That he prescribed IV metoprolol verbally without first having reviewed Mr A and that he initialled the medication chart without correcting the error that it be administered ‘stat’.

Te Whatu Ora

104.          Te Whatu Ora acknowledged that at the time of the events there was an increasing demand for acute services with limited capacity to manage the volume. Te Whatu Ora said that several measures were implemented to reduce the risk to patients, including staff education, implementation of the EWS system, and a process of escalation of deteriorating patients to the appropriate specialists.

105.          Te Whatu Ora said that it is aware that its staff faced challenges at the time of the events and that some of the issues identified in the provisional opinion are due to systemic issues, rather than the fault of the individual clinicians.

Opinion: Te Whatu Ora — breach

Introduction

106.          First, I express my sincere condolences to Mr A’s family for their loss.  

107.          To consider whether the care provided to Mr A was reasonable, I was guided by the independent advice from Dr Kenneth Clark, who is vocationally registered with the Medical Council of New Zealand in Medical Administration,[58] and a fellow of the Royal Australasian College of Medical Administrators. Dr Clark was the Chief Medical Officer of MidCentral District Health Board from 2002 until 2019.

108.          As a healthcare provider, Te Whatu Ora is responsible for providing services in accordance with the Code of Health and Disability Services Consumers’ Rights (the Code). It had a responsibility to ensure that the hospital was sufficiently resourced, and that Mr A received services of an appropriate standard from experienced, suitably trained, and supported staff. While there is certainly individual accountability and obligations on individual providers to provide care within accepted standards, Te Whatu Ora has an organisational responsibility to provide a reasonable standard of care to its patients. I consider that a combination of inadequate staffing and support affected the care provided to Mr A. I find that Te Whatu Ora breached Right 4(1)[59] of the Code. The reasons for my decision are set out below.

Staffing and staff training

109.          On Days 2 and 3, Dr C, a doctor at junior level, was the only house officer on the night shift. Dr C told HDC that the ‘workload at night was unmanageable and unsafe for just the one junior doctor’.

110.          Dr Clark advised that the key issues in relation to the staffing levels were Dr C’s workload in respect to bed and patient numbers, the patient acuity mix, the other duties for which Dr C was responsible, and the support and escalation mechanisms available to Dr C.

111.          Dr Clark advised that the RMO/intern staffing at night at the time of Mr A’s admission was inadequate and not in the best interests of the patients, their whānau, or the clinical staff. Dr Clark considers this to be a moderate departure from the accepted standard. Dr Clark advised:

‘Realities of high patient demand, with increasing complexity and acuity, are seen across the entire health sector. Equally resource constraints are recognised, however in this situation the provider has not ensured adequate staffing levels at night — and has placed excessive clinical responsibility on an Intern, both on this particular shift and it appears on a number of other shifts over time.’

112.          I accept Dr Clark’s advice. I am aware of the pressure hospitals are under at a national level due to an increase in demand, workforce shortages and recruitment challenges. However, fundamentally, healthcare consumers have the right to expect hospitals to be sufficiently resourced with the appropriate mix of skilled and experienced staff to provide safe and competent care. In my view, Dr C was not provided with adequate supervision, given his level of experience, and the support available to Dr C was inadequate.

113.          The acuity, staffing levels, and the lack of staff training on the Prescribing Policy and verbal medication orders suggests that this was a service delivery failure on the part of Te Whatu Ora.

114.          I note that since the events, Te Whatu Ora has reviewed its safe staffing levels on night shifts and has added medical registrars to the RMO workforce.

Communication with whānau

115.          To consider whether the communication with Mr A’s whānau was appropriate, I was guided by the independent advice from RN Julia Braid.

116.          Mr A’s condition started to deteriorate from 12.00am on Day 2 but Mr A’s whānau was not contacted until the rapid response call was made at approximately 4.30am on Day 3.

117.          RN Braid advised:

‘In my opinion, the family were not communicated with in an empathetic or timely manner after 11pm as [Mr A’s] condition continued to decline. Therefore, denying them an opportunity to decide if they wanted to be at his bedside during the night, and denying [Mr A] possible comfort of their presence in his confused state. This is a serious departure from standards.’

118.          I accept RN Braid’s advice. Given that Mr A’s condition was deteriorating, I would have expected Mr A’s family to have been contacted earlier, and I am critical that this did not occur.

Conclusion

119.          In my view, Te Whatu Ora failed to provide services to Mr A with reasonable care and skill for the following reasons:

·     The staffing levels, supervision, and support provided to the medical staff at the time of the events were inadequate;

·     There was a lack of training for medical staff on the Prescribing Policy, resulting in IV metoprolol being prescribed over the telephone without a review of Mr A; and

·     The communication with Mr A’s whānau was inadequate.

120.          Accordingly, I find that Te Whatu Ora breached Right 4(1) of the Code.

Opinion: RN B — breach

121.          To consider whether the care provided by the nursing staff was reasonable, I was guided by the independent advice from RN Julia Braid.

122.          Having undertaken a thorough assessment of the information gathered, I find that RN B breached Rights 4(1)[60] and 4(2)[61] of the Code. The reasons for my decision are set out below.

Care provided

Escalation of care

123.          Mr A was in a stable condition immediately following his surgery on Day 2. He was transferred to ICU at 1.15pm on Day 2, and by approximately 4.00pm he was reported to be comfortable, and his abdominal pain had improved.

124.          Later that evening, at 9.45pm, Mr A was reviewed by Dr F for signs of possible myocardial ischaemia. Dr F did not consider that any intervention was necessary at that stage but directed the nursing staff to monitor Mr A’s blood pressure, heart rate, oxygen saturation, and chest pain.

125.          Care of Mr A was handed over to RN B at 11.15pm on Day 2.

126.          Initially, RN B said that she discussed with Dr C the difference between Mr A’s arterial line blood pressure and non-invasive blood pressure at the beginning of the shift. Subsequently, however, RN B said that this discussion was with Dr F, and not Dr C. This is not documented in RN B’s clinical records, which she documented retrospectively. Dr C said that he was not made aware of any concerns about Mr A’s condition until around 3.00am on Day 3, when Mr A had gone into atrial fibrillation.

127.          Due to the differing statements presented by Dr C and RN B and the lack of detail in the clinical documentation, I am unable to determine when RN B first informed Dr C of her concerns about Mr A’s condition.

128.          Mr A’s condition deteriorated from 12.00am on Day 2. At 12.00am, Mr A’s heart rate started to increase, and his urine output and GCS score started to decrease. Mr A’s blood pressure also started to decrease gradually. RN B stated that it was not Mr A’s blood pressure in itself that was of concern, but the clinical presentation in its totality, ‘noting the subtle changes in trends with [a decreasing] level of consciousness, [an increasing] heart rate, change in rhythm and fluid imbalances which [led] to concern’. Given the overall clinical picture, at this point, RN B should have escalated care of Mr A to the relevant senior medical staff, and I am critical that this did not occur. This was a missed opportunity to recognise Mr A’s deteriorating condition, and to provide treatment.

129.          There was a period of three hours (from 12.00am until 3.00am) during which Mr A’s blood pressure continued to drop, and his condition continued to deteriorate. As set out above, I am unable to determine when RN B first informed Dr C about the concerns with Mr A’s condition. In any event, regardless of whether RN B informed Dr C of any concerns at the beginning of the shift, I am critical that RN B took no action until approximately 3.00am, when Mr A went into atrial fibrillation, and she paged Dr C for assistance.

130.          Upon receiving the page from RN B at around 3.00am, Dr C was unable to attend Mr A because other patients required review. In my view, this was another missed opportunity for RN B to escalate the care of Mr A to the on-call senior medical staff.

131.          RN Braid advised that the escalation of care was inappropriately delayed until the rapid response team was called at 4.25am on Day 3. RN Braid referred to Te Whatu Ora’s ICU Guideline, which states that deteriorating patients will be identified to the RMO by the senior nurses on duty. The ICU Guideline also states that the RMO will contact the SMO to discuss the patient, and that in some circumstances, the senior nurse on duty may escalate the process and contact the SMO directly. RN Braid advised:

‘In my opinion, nursing staff missed opportunities to act on this principle to seek advice and obtain a senior medical officer review of [Mr A] and is a severe departure from standards.’

132.          I accept RN Braid’s advice. Regardless of whether RN B informed Dr C or Dr F of her concerns at 11.00pm on Day 2, the lack of action taken by RN B when Mr A’s condition started to deteriorate from 12.00am to 3.00am on Day 2 is a significant departure from the accepted standard of care.

133.          In my view, Mr A’s deteriorating clinical condition and the lack of medical review warranted escalation by RN B to the senior medical staff.

134.          I note RN B’s statement that ‘having the on-call [house officer] prioritise care elsewhere in the hospital was a regular occurrence on night duty’. As commented on by Dr Clark, this in itself is not a reason for nursing staff to fail to escalate care of a patient, and it is not in line with the ICU Guideline.

135.          Dr Clark similarly advised that there was a lack of communication and escalation of care between 11.00pm on Day 2 and 4.30am on Day 3. Dr Clark stated:

‘There was a lack of communication by nursing staff with medical staff — firstly communication with [Dr C] in the hours between 2300 and 0300. In this context, it is possible that [Dr C] was either not responding to calls made to him, or was not available because of various other patients and duties for which he was responsible. If this were so, the nursing staff should have considered communicating directly with the relevant senior medical officers, whether that be surgical or anaesthetic, according to the relevant policies and procedures applying to patient management in the ICU … Equally, [Dr C] should have considered contacting the on-call senior medical staff himself, given that he was unable to respond in full to the requests of the ICU nursing staff …

I do not believe that appropriate escalation of care occurred between 2300 and 0430. This is in respect to nursing staff not making earlier formal communication with [Dr C], whether that be by the paging system or telephone — and in respect to [Dr C’s] failure to escalate to senior medical staff when he was contacted at 0300 but did not attend [Mr A] in person.’

Blood pressure monitoring

136.          RN B stated that at the time of her assessment of Mr A at 11.00pm, she noted a disparity between the arterial line blood pressure and the non-invasive blood pressure. Initially, RN B said that she recalls having a discussion with Dr C in relation to Mr A’s blood pressure, and that Dr C drew a diagram to explain the findings, and Mr A’s diagnosis with right subclavian stenosis. Subsequently, however, in response to the provisional opinion, RN B said that her discussion about Mr A’s blood pressure was with Dr F, and not Dr C. RN Braid advised:

‘In my opinion when best practice for the management of arterial pressure lines is followed … the arterial line is the most accurate method to measure blood pressure and mean arterial blood pressure trends. During her shift [RN B] believed the blood pressure change she was seeing was explained by the arterial line not accurately measuring blood pressure, in the context of R) subclavian stenosis. She stated that she was given an explanation and a diagram by [Dr C] which she accepted, and she chose to use manual L) arm [blood] pressure measurements as the basis of blood pressure assessment … She continued to believe the significant difference in blood pressure measurements was that the manual cuff provided accuracy rather than [Mr A’s] condition was acutely deteriorating. She appears to have lost situational awareness as she maintained this stance throughout the shift.

In my opinion, after troubleshooting any issues, and if in doubt regarding the patency of accuracy of the arterial line a phone call to the On-Call Anaesthetist for advice is the favoured option.’

137.          RN Braid advised that in a haemodynamically[62] unstable patient, non-invasive measures will be more inaccurate, making the invasive measurement more reliable, even if it were taken from a more distal artery. RN Braid advised that the dismissal of invasive arterial pressure monitoring in favour of non-invasive blood pressure monitoring in the context of a high acuity patient with bowel perforation, peritonitis,[63] new cardiac changes, and worsening multi-organ function, is a severe departure from accepted practice.

138.          I accept RN Braid’s advice. I am critical that RN B failed to recognise the significance of the invasive arterial blood pressure measurement trend, particularly given the other clinical signs that Mr A’s condition was deteriorating.

139.          I acknowledge RN B’s recollection that she discussed her concerns about Mr A’s blood pressure with either Dr C or Dr F at 11.00pm but due to the lack of documentation, I am unable to make a finding that this occurred.

EWS

140.          From 11pm on Day 2 to 5.00am on Day 3, RN B did not total and document the EWS each time she measured the vital signs. In addition, from midnight to 3.00am on Day 3, RN B documented Mr A’s respiratory rates in the incorrect rows of the EWS chart. RN Braid advised that if the respiratory rates had been recorded in the correct rows, it would have resulted in additional points and a total EWS of 4 to 6.

141.          RN Braid advised that due to reduced medical staffing after hours, nurses manage patients in the ICU/HDC/CCU with reduced levels of medical officer support. RN Braid said that the reliance on nursing staff to manage unwell patients within the system of reduced medical staff involvement, particularly on night shifts, depends on trusted communication processes (such as SBARR[64] and the EWS pathway). RN Braid advised that the registered nurse is accountable for providing accurate assessment and to escalate care appropriately, which is ‘how many comparable ICU/HDU/CCUs have historically run in New Zealand’.

142.          RN Braid said that the capacity to detect early deterioration is reduced when the EWS is incomplete. RN Braid advised:

‘In my opinion, hourly or more frequent assessment of [Mr A] using the “head to toe” approach and accurately completing the EWS chart should have triggered hourly escalations or updates to [Dr C]. As even in the absence of accurate blood pressure and a temperature recording his EWS scores were elevated, if calculated correctly …

To summarise it is my opinion, the EWS chart was inappropriately used during the period [Mr A] was deteriorating. The failure to undertake full observations, to chart and calculate them correctly in a patient with this condition is a severe departure from accepted practice.’

143.          I accept RN Braid’s advice. I am critical that RN B failed to complete the EWS chart accurately, and that she failed to total and document the scores. The purpose of the EWS escalation and response pathway is to assist staff to make reasoned decisions where there is evidence of deterioration, and to ensure an appropriate level of escalation and response.

144.          As commented on by RN Braid, the significance of RN B recording the respiratory rates in the incorrect rows is that the total EWS was ‘falsely low’, which failed to prompt further escalation, response, or investigations into the causes.

145.          In my view, the inaccurate and incomplete EWS by RN B contributed to the failure to recognise Mr A’s deteriorating clinical condition, and in care of Mr A not being escalated appropriately.

Conclusion

146.          In my view, RN B failed to provide services to Mr A with reasonable care and skill for the following reasons:

·     Mr A’s care was not escalated appropriately;

·     Mr A’s blood pressure was not monitored adequately; and

·     The EWS was not used appropriately (the chart was not completed fully and accurately).

147.          Accordingly, I find that RN B breached Right 4(1) of the Code.

Documentation

148.          RN B took over the care of Mr A from 11.15pm on Day 2, but she documented the care retrospectively at 3.55am on Day 3.

149.          Given the acuity of the night shift, it was not unreasonable for RN B to have completed her clinical records retrospectively at 3.55am on Day 3. The clinical records are still contemporaneous and in line with the Nursing Council of New Zealand’s standards. I am therefore not critical that RN B did not document her entries in the clinical records earlier.

150.          I am, however, critical that RN B did not document her care of Mr A for the period from 3.55am to 7.00am on Day 3. RN B did not document the administration of metoprolol, her assessment of its effect on Mr A, or Mr A’s condition during this period. RN Braid advised that she considers this failure to be a severe departure from acceptable practice.

151.          I accept RN Braid’s advice. The Nursing Council of New Zealand Code of Conduct for Nurses states: ‘Keep clear and accurate records of the discussions you have, the assessments you make, the care and medicines you give, and how effective these have been.’

152.          I acknowledge the acuity of the night shift and the challenging circumstances that RN B was working under at the time of the events. However, I am critical that RN B did not document her assessments and discussions with staff adequately.

153.          RN Braid also advised that if Dr C’s verbal order was for metoprolol to be administered in a ‘slow push’ and not ‘stat’, as documented by RN B, this ‘miswording’ represents a moderate departure from the accepted standard.

154.          RN B said that the word ‘stat’ on the medication chart was intended to mean ‘give it now’ and was not intended to mean ‘just push in the drug/dosage’.

155.          Due to the lack of documentation, I am unable to determine what Dr C’s verbal instructions were in relation to the administration of metoprolol and whether it was to be administered ‘stat’, or in a ‘slow push’. I am critical that RN B did not document her discussion with Dr C in relation to the verbal prescription of metoprolol. If RN B had done so, this would have clarified how metoprolol should have been administered, and the intention behind the word ‘stat’ that is written on the medication chart. Further, RN B could have requested Dr C review Mr A, rather than rely on a verbal order for this medication.

156.          In my view, RN B’s documentation was not up to the standard required by the Nursing Council of New Zealand and, accordingly, I consider that RN B breached Right 4(2) of the Code.

Opinion: Dr C — adverse comment

Escalation of care

157.          RN B and Dr C presented differing versions of the events. RN B said that she discussed with Dr C the difference between Mr A’s arterial line blood pressure and non-invasive blood pressure at the beginning of the shift (at around 11pm). This is not documented in RN B’s clinical records, which she documented retrospectively. On the other hand, Dr C said that he was not made aware of any concerns about Mr A’s condition until around 3.00am on Day 3, when Mr A had gone into atrial fibrillation.

158.          Due to the differing statements presented by Dr C and RN B and the lack of detail in the clinical documentation, I am unable to make a finding of fact as to whether RN B informed Dr C about the concerns with Mr A’s blood pressure at the beginning of the shift (at around 11.00pm), or whether she informed him about the concerns only at around 3.00am, when Mr A had gone into atrial fibrillation.

159.          Upon receiving the page from RN B at around 3.00am, Dr C was unable to attend Mr A because other patients required review. I am critical that Dr C did not escalate care of Mr A to the on-call senior medical staff when he was unable to review Mr A at around 3.00am. In my view, this was another missed opportunity for the care of Mr A to be escalated to the on-call senior medical staff.

160.          As advised by Dr Clark, I acknowledge that there were multiple contributory factors at an organisational level that affected the care provided to Mr A. There was inadequate medical staffing during the night shift on Day 2, which placed excessive clinical responsibility on Dr C. Dr C was also not provided with adequate supervision, given his level of experience, and the support available to Dr C was inadequate. In my view, however, these factors did not absolve Dr C from his responsibility to escalate the care of Mr A when he was unable to review him at around 3.00am.

Medical review

161.          The ICU Guideline states that clinical management of the ICU patient should include two bedside patient reviews per day, conducted by the SMO team, and that a request to review a patient at the bedside in ICU must be met by a member of the primary team, or the covering on-call team, in less than 15 minutes.

162.          Mr A was reviewed by Dr F at 9.45pm on Day 2.

163.          At around 3.00am on Day 3, RN B paged Dr C for assistance, but Dr C was unable to review Mr A because other patients required review at that time. Dr C stated that he was not asked to review Mr A, and that had he been made aware that Mr A’s blood pressure had been deteriorating steadily since 11.00pm, he would have done so.

164.          Dr Clark advised that the lack of attendance by Dr C was not in keeping with the ICU Guideline. However, Dr Clark said that there were multiple mitigating factors (such as the staffing levels and acuity) and given the circumstances under which Dr C was working at the time, Dr Clark considers this to be a mild departure from accepted practice.

165.          I accept Dr Clark’s advice. Dr C should have undertaken a bedside review of Mr A, and he should have reviewed Mr A within 15 minutes from the time when he received the call/page for assistance at around 3.00am. I am critical that this did not occur. If Dr C was unable to review Mr A, he should have asked the on-call SMO to review Mr A.

166.          There was no medical review of Mr A for approximately seven hours (from 9.45pm on Day 2, until approximately 4.30am on Day 3, when Mr A was reviewed by the rapid response team). This was not appropriate care.

167.          In my view, the key issue is that there were critical missed opportunities to escalate care when it became evident that Mr A’s condition was deteriorating, and, as a result, Mr A was not reviewed by medical staff.

168.          I acknowledge, however, that largely this can be attributed to the challenging environment and pressure under which Dr C was working at the time of events. Dr C was a junior doctor and the only house officer on the night shift.

Verbal prescription

169.          At some time between 3.00am and 4.00am on Day 3, Dr C gave a verbal order for Mr A to be administered IV metoprolol, without having reviewed Mr A.

170.          Dr Clark considers this to be a moderate departure from the accepted standard of care. Dr Clark advised:

‘[I]n the Intensive Care Unit circumstance any significant clinical change should result in a bedside review by the responsible medical team — in this case, by [Dr C], or if he was simply not able to attend because of other clinical commitments, by escalation to the relevant senior medical staff. Verbal prescription has a small but definite place in health care, but in the context of patients in an intensive care or high dependency facility, it is my opinion that it should only be done in exceptional circumstances.’

171.          I accept Dr Clark’s advice. I am concerned that Dr C prescribed IV metoprolol verbally and without having reviewed Mr A. I note, however, that Dr C confirmed his verbal order for Mr A to be administered IV metoprolol by initialling the medication chart at 4.10am, in accordance with the Prescribing Policy. Te Whatu Ora also considers that Dr C followed the Prescribing Policy.

172.          The IV metoprolol was administered stat, but Dr C stated that his instruction was for it to be administered as a slow push. It is documented on the medication chart that metoprolol was to be administered ‘stat’. Dr C stated that this was not his instruction, and that he had asked for the metoprolol to be administered in a ‘slow push’, which meant ‘small increments of about 1mg with a minute between each push’. This is indicative of the communication issues that can arise when giving verbal prescriptions. Due to the lack of documentation, I am unable to determine what Dr C’s instruction was. If Dr C’s instruction was for metoprolol to be administered in a ‘slow push’, then I am critical that he signed off on the medication chart, which stated that metoprolol was to be administered ‘stat’.

173.          I consider that it was Dr C’s responsibility to ensure that the verbal prescription was correct. If the medication chart was not in accordance with his instruction, I am critical that he did not remedy this when he signed off on the medication chart.

174.          I acknowledge, however, that there are numerous mitigating factors on the part of Dr C. Dr C was aware of Mr A’s medical history and regular medications, as he admitted Mr A to the surgical ward on Day 1. Dr C was also reassured by the seniority and clinical experience of RN B. It is also possible that Dr C was not provided with all the relevant information about Mr A’s condition at that time. In addition, Dr C told HDC that he received no training or education about verbal medication orders.

Changes made since events

RN B

175.          RN B told HDC that she is no longer practising as a nurse.  

Te Whatu Ora

176.          Te Whatu Ora told HDC that significant changes have been made since the events, which are set out below.

Quality and clinical governance

177.          Te Whatu Ora said that it is strengthening Clinical Governance activities, with additional staff recruited into the Quality Department. Te Whatu Ora anticipates that this will improve its capacity and capability to investigate serious incidents and ensure that any learnings are shared with the wider organisation. Te Whatu Ora said that the following changes have been made:

·        The appointment of a Director and two Associate Directors of Quality;

·        Weekly multidisciplinary Quality meetings;

·        Monthly meetings of the Clinical Board;

·        The implementation and appointment of second tier Nursing Leadership to support clinical nurse managers, which has a focus on education and quality; and

·        An increase in the nursing workforce with an uplift of staff on night shifts.

Medical workforce

178.          Te Whatu Ora said that it has reviewed safe staffing levels on night shifts, and it has added medical registrars to the RMO workforce, which has provided an additional layer of safety on night shifts. Te Whatu Ora said that the following changes have been made to the medical workforce:

·        An increase in the number of medical staff working overnight. Te Whatu Ora stated that currently it has a medical registrar and a house officer working overnight, with specialists on call, and since February 2024, a physician has been working overnight on some of the overnight shifts; and

·        An increase in the RMO workforce with the addition of registrars in General Medicine, ED, and Orthopaedics.

ICU

179.          Te Whatu Ora stated that training for nursing staff has been increased, with staff having access to several courses, including the BASIC course.[65]  Te Whatu Ora also said that the ICU has undergone an external review and that the following changes have been made:

·        The employment of two intensivists to standardise ICU practices, provide clinical support to nurses, consult and advise the primary team on critically ill patients, provide leadership, nurture a collaborative and high-quality ICU team and provide surgical and medical teams with an accountable ICU leader;

·        Appointment of a full-time ICU-specific clinical nurse manager with extensive ICU experience to help maintain standards, including nursing support, and foster a culture of safety and accountability;

·        The institution of daily multidisciplinary rounding, which includes allied health professionals (pharmacy, physiotherapy, dietary), as well as palliative care and kaiatawhai[66] support;

·        ICU clinical coaches to support nursing competency and education; and

·        A crash simulation programme specific to ICU nursing staff to practise crash scenarios to improve teamwork and communication and provide regular practice for a high-stake low frequency event.

Implementation of Te Tāhū Hauora|Health Quality & Safety Commission deteriorating patient programme

·        Implementation of EWS on wards and ICU;

·        Regular auditing of EWS charts to ensure compliance and accuracy of EWS calculations and appropriate escalation; and

·        Implementation of a simulation programme for house officers and nurses in acute deteriorating patient scenarios to build confidence, reinforce clinical decision-making, and develop teamwork skills.

180.          In relation to the EWS system, the Director of Nursing told HDC:

‘Many iterations have taken shape with the tool being adapted from Waikato DHB. Per Clinical Coach, the EWS component, utilisation and scenario based escalation drills were socialised with nursing staff through in-services until all ICU staff were captured. Blood pressure assessment specifically pertaining to the critical care setting occurs during induction/orientation to the ICU. My findings show that is adequate.’

181.          Te Whatu Ora said that it is pleased with the significant progress made over the last few years. Te Whatu Ora stated:

‘We are confident that the issues identified in the review have been addressed. We believe the work to strengthen the ICU, RMO educational programme, improve staffing at night and Clinical Governance in the organisation will go a long way in improving the quality of care we provide at Gisborne Hospital.’

Recommendations

182.          Considering the changes made by Te Whatu Ora since the events, I recommend that Te Whatu Ora Tairāwhiti:

a)     Provide a formal written apology to Mr A’s family for the deficiencies in care identified in this report. The apology should be sent to HDC, for forwarding to Mr A’s family, within three weeks of the date of this report.

b)     Provide all current staff with training on the deteriorating patient, with an emphasis on the EWS system and escalation, including to whom care is to be escalated and by whom. Evidence of this is to be provided to HDC within six months of the date of this report. As suggested by Dr Clark, this should include multidisciplinary team simulation exercises to ‘workshop’ responses and, where required, escalation of care. Evidence of this is to be provided to HDC within six months of the date of this report.

c)     Provide all medical staff with training on the practice of verbal prescriptions in the critical care setting. As recommended by RN Braid, Te Whatu Ora Tairāwhiti should also consider whether an advanced medications list, providing guidance on the roles and designations that can administer medications such as metoprolol, is warranted. Evidence of this is to be provided to HDC within six months of the date of this report.

d)     Provide HDC with the updated ICU EWS chart that includes changes to the escalation pathway and improvements for documentation. The updated ICU EWS chart is to be provided to HDC within six months of the date of this report.

e)     Review and update its EWS Policy and procedures to reflect the implementation and use of EWS in the ICU/CCU. The updated policies and/or procedures are to be provided to HDC within six months of the date of this report.

f)      Review and update its ICU Guideline to strengthen the escalation and response system available, as recommended by RN Braid. The updated guideline is to be provided to HDC within six months of the date of this report.

g)     Report on the effectiveness of the changes made in relation to staffing and the workloads of staff at night. Effectiveness should be measured via an audit of incidents occurring in relation to escalation of care. The audit’s summary of findings, with corrective actions implemented/to be implemented should any incidents be reported, is to be provided to HDC within six months of the date of this report.

h)     Ask senior clinical staff (including the Chief Medical Officer) to reflect on the systems in place for deployment of SMOs outside of hours, and on the current culture of availability and responsiveness of SMOs outside of hours, and report back to HDC on their reflections within six months of the date of this report.

i)      Prepare and present an anonymised case study of this case for wider education of medical and nursing staff at Te Whatu Ora Tairāwhiti. The case study should detail the actions taken and decisions made by the staff, the results of these actions/decisions, and the appropriate course that should have been taken to arrive at a more desirable outcome. Evidence confirming the content and date of the presentation, and the staff to whom it has been presented, is to be provided to HDC within six months of the date of this report.

183.          I recommend that RN B provide a formal written apology to Mr A’s family for the deficiencies in care identified in this report. The apology should be sent to HDC, for forwarding to Mr A’s family, within three weeks of the date of this report. Taking into account that RN B is no longer practising, I recommend that should RN B return to practice, she:

a)        Undertake training on the deteriorating patient, with an emphasis on the EWS system and escalation, including to whom care is to be escalated and by whom.

b)        Undertake training on documentation.

c)         Undertake a competence review, with the assistance of the Nursing Council of New Zealand.

184.          Considering the changes made and the significant training undertaken by Dr C since the events, I consider that no recommendations are necessary.

Follow-up actions

185.          A copy of this report will be provided to the Coroner.

186.          A copy of this report with details identifying the parties removed, except Te Whatu Ora Tairāwhiti, Gisborne Hospital, and the advisors on this case, will be sent to the College of Intensive Care Medicine of Australia and New Zealand, and the College of Nurses Aotearoa (NZ).

187.          A copy of this report with details identifying the parties removed, except Te Whatu Ora Tairāwhiti, Gisborne Hospital, and the advisors on this case, will be sent to the Nursing Council of New Zealand, and it will be advised of RN B’s name.

188.          A copy of this report with details identifying the parties removed, except Te Whatu Ora Tairāwhiti, Gisborne Hospital, and the advisors on this case, will be placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.