Human Rights Review Tribunal | Director of Proceedings v Health New Zealand [2024] NZHRRT 52
(29 October 2024)
The Director of Proceedings filed proceedings by consent against Health New Zealand | Te Whatu Ora (“Health NZ”) (formerly Auckland District Health Board (“ADHB”)) in the Human Rights Review Tribunal (“the Tribunal”) regarding the care provided to Mr Trevor Flood (“Mr Flood”) at Auckland City Hospital.
In January and February 2019, Mr Flood was receiving curative intent radical radiation treatment from the ADHB Radiation Oncology Service at Auckland City Hospital for oropharyngeal cancer. During this time, Mr Flood was admitted to the oncology ward due to complications from his radiation treatment. For his pain, Mr Flood was prescribed subcutaneous morphine (an injection) to be administered hourly as required. If Mr Flood’s pain could not be managed adequately, morphine would be provided through a syringe driver which administered the morphine as an infusion (i.e. morphine is administered continuously over a set period and at a controlled rate).
Mr Flood’s pain continued, and as such, the amount of morphine given was increased. Three days after admission, it was observed that Mr Flood had very low oxygen levels in his blood, a low respiratory rate, and had impaired consciousness. Consequently, a Code Red (clinical emergency) was called.
Mr Flood was transferred to the Department of Critical Care Medicine where he was diagnosed with opioid narcosis (opioid induced ventilatory impairment from opioid (morphine) administration). Mr Flood was given naloxone to reverse the effects of the morphine. He was then reviewed by the Acute Pain Service and started on a patient-controlled analgesia pump with intravenous fentanyl. He was transferred back to the oncology ward with a diagnosis of “opioid narcosis – resolved”.
Mr Flood’s radiation treatment resumed, and he was discharged in early March.
After a couple of weeks, Mr Flood started to display symptoms of confusion, reduced coordination, and altered speech. An MRI scan showed changes to his brain, typically seen with chronic hypoxia or toxic injury.
Mr Flood’s cognitive changes intensified, and in late April he was reviewed by a neurologist. It was determined that Mr Flood had experienced a serious brain injury and was diagnosed with delayed post-hypoxic leukoencephalopathy. This is a rare condition where damage to the protective covering of the nerves causes symptoms days to weeks following apparent recovery from coma after a period of cerebral hypoxia (low levels of oxygen in the brain), in Mr Flood’s case due to opioid toxicity.
Independent advice provided to the Health and Disability Commissioner confirmed that it was not clear that the clinical team appreciated the potential impact an increase in morphine through a continuous infusion could have on Mr Flood.
The advisers noted that there were systemic issues related to morphine prescribing. These stemmed from the lack of clear policies and guidelines within the Radiation Oncology Service at ADHB. The advisers criticised the lack of adequate documentation by several staff, in particular the Code Red event not being recorded in medical notes.
The ADHB’s adverse event review identified that there was an inappropriate use of a continuous subcutaneous infusion and that there was no ADHB-wide policy on when and how to use continuous subcutaneous infusions, frequency of medical reviews, and patient monitoring. The ADHB also acknowledged that the frequency of vital sign monitoring was suboptimal, and that inadequate staffing and documentation contributed to the delay of recognition and timely management of Mr Flood’s condition.
Health NZ accepted that its failures breached the Code of Health and Disability Services Consumer’s Rights (“the Code”) and the matter proceeded by way of an agreed summary of facts. The Tribunal was satisfied that Health NZ failed in the care provided to Mr Flood and issued a declaration that it breached Rights 4(1) and 4(4) of the Code.
The Tribunal’s full decision can be found at: