‘Unacceptable’: Man dies after hospital keeps him in ED for hours, misses notes, fails to order scan

The man, named only as Mr A in the report by Deputy Health and Disability Commissioner Deborah James, was in his 80s when he collapsed at his care home in 2020. He had a 10cm on the head.

Ambulance personnel who took him to the emergency department (ED) brought a yellow envelope provided by the nursing home, containing the man’s medication chart and other information, in accordance with long-standing practice.

The yellow envelope was lost in the hospital.

The paramedics said they gave it to someone behind a glass screen in the ED lobby. Two receptionists working shifts said they did not remember being given it.

The ED secretary, called Dr C, said that Mr A was placed in a wheelchair in the waiting room and assigned to a triage group which meant he was to be seen within 60 minutes.

Dr C said he moved Mr A to the fast-track ED at around 2am, when he had been in the ED for four hours, and the registered nurse took his views. the first at 6.30am.

The patient did not know which city he was in

At the time his “alert notes” did not indicate concern, but the notes also stated that Mr A could not give his date of birth or say what city he was in.

At 6.57am, Dr C realized that Mr A had been waiting for a long time to be seen, smelled of urine that was strong and had a bladder full of urine.

He had a normal pulse and normal sensation and strength in his limbs, and normal hand coordination, but he did not understand test instructions and was “slow and shaky.” .

Dr C did not know that Mr A was taking Warfarin – a blood thinner used to prevent bleeding. This information was in a yellow envelope, which he did not see.

Dr. C said that since he did not know that Mr. A was using anticoagulants, he did not order a head CT scan.

He told the commissioner that if he had known he was on Warfarin, “his routine would have been to do a CT of his brain before he was discharged”.

After Mr. A’s head wound was treated, he was kept in the ED for observation, but remained in a wheelchair due to a lack of beds.

On delivery at 8am, Dr C told consultant Mr A that the wound had been inserted and he seemed stable after his night in the ED.

The consultant asked if Mr A was taking anticoagulants and Dr C said he believed he was not.

Mr A was returned to his care home at 10am.

The nursing home referred him to his general practitioner the next day because he was unwell with confusion and tremors.

The patient’s life is reduced

On Day 8, there was a further decline in his life. He could not open his eyes, speak or move his arms and legs.

He was taken back to Southland Hospital where a quick CT scan showed he was bleeding heavily and hospital staff discovered he was on Warfarin.

He was hospitalized where, despite modified Warfarin therapy, he died.

Dr C told the HDC that doctors working in the ED overnight were discouraged from ordering CT scans unless they were urgently needed, due to issues including calling radiographers from home, which were it will affect the service the next day.

“I accept … what is given [Mr A’s] the condition of the operation and the condition in which CT of the head was indicated, and I regret and am sorry for not fixing this earlier [Mr A’s] out,” said Dr C.

“This case and the ideas and lessons it produced are ongoing, and will continue to inform my practice,” said Dr. C, who has since moved.

Health New Zealand, which oversees the hospital, said at the time of the incident it was running an on-call service for patients needing urgent CT scans at night, and nurses were asked to request the facilities. warning for patients whose control is immediate. it depends on the results.

This was to ensure that the day-to-day operation of the service was not “unduly affected”.

The man’s son said it appeared that the hospital’s support was poor, but that reducing CT rates due to staff shortages “seems to put financial problems ahead of patient care and this is disappointing”.

Dr C says he remembers feeling “overwhelmed” by the number of patients waiting to be seen, and the lack of places to see them, on the night Mr A was brought.

The HDC found Dr C had violated Mr A’s patient rights, and agreed to issue a written apology to his family.

Deputy commissioner James also found that Health NZ Southern had breached Mr A’s patient rights.

He said he was an elderly man who had been forced to wait four hours in the ED waiting area “when he was clearly in distress” and another two and a half hours in the urgent care area before seen. initial expectations.

This happened despite the triage team saying he should have been seen within the hour.

“This is unacceptable care for a patient with a head injury, regardless of whether it was known at the time that he was on Warfarin,” James said.

NZ’s southern medical officer, David Gow, said the agency accepted the findings and recommendations of the James report.

“Our goal is to provide quality health care at all times, and we deeply regret that in this case we did not meet those high standards,” Gow said.

“We have apologized to the patient’s family for the shortcomings noted in the report that caused this tragic outcome.”

Gow said steps taken to implement the report’s recommendations include working with Hato Hone St John to standardize the practice of handing out yellow envelopes to emergency department staff, and providing “ongoing training to staff to reduce the danger of an incident like this happening again”.

Ric Stevens spent many years working for the former New Zealand Press Association, including as a political reporter in Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.