11 Feb 2020

Woman dies after 'sub-optimal' care following blood test - Commissioner

7:09 am on 11 February 2020

A young woman died after Auckland District Health Board provided her sub-par care following an intravenous blood test, the Health and Disability Commissioner has found.

Iv Drip in hospital corridor

File photo. Photo: 123rf

Commissioner Anthony Hill found the health board breached the Code of Rights in its care for the woman, who had a fatal septicaemia-induced heart attack days after a blood test. She is not named, nor is the hospital nor any staff.

The woman's mother said she thinks her daughter would still be alive had things been different, stating details of her care were omitted, ignored or not taken seriously.

Following an operation in 2017, the 20-year-old had a catheter inserted to take blood for testing. A pus-like substance was found near the site of the needle, and a swab was taken. This was not documented nor communicated to the woman's GP.

One day after she was discharged, a the returned swab result showed "heavy growth" of a type of bacteria that commonly causes a skin infection.

The following day the woman's mother notice she was "very lethargic", and took her to her GP. The discharge summary the GP was working with had no reference to the swab being taken. She was rushed to hospital where she was diagnosed with septicaemia, or blood poisoning.

While at the hospital the swab result from the previous day was looked at for the first time.

The woman deteriorated quickly and died the following morning from a septicaemia-induced heart attack, while in hospital.

"I believe my daughter would still be alive had certain events not taken place in the first place," the woman's mother said in the report.

"I believe these small details were either omitted, ignored or not taken seriously... The swab was never taken seriously," she said.

Hill found Auckland DHB's care was "sub-optimal", and recommended it formally apologise to the woman's family and make changes to its policies.

Two months after an operation for a heart issue, in which she received a pacemaker, the woman returned to the hospital for post-operative tests. It remained in overnight. The woman's clinical notes don't show any of the nursing staff checked the catheter at any point following its insertion to the point when she was discharged the following afternoon, when she was allowed to leave overnight with the catheter still in place. She is referred to as Ms A in the report.

"Auckland DHB said that it is unclear who made the decision to allow Ms A to go on leave from the ward with a PIVC in place. It said that the vascular surgeon was unaware that the IV line had been left in situ during Ms A overnight leave," the report said.

She returned to hospital the following day unable to bend her arm and in pain. The intravenous line was removed and there were pus spots near the insertion, which she pointed out to the nurse who said it was "fine".

Another nurse and doctor checked the site but did not raise any concerns about the possibility of an infection.

"[A doctor] said that the 'insertion site did not look obviously infected', and Ms A looked otherwise well, and that a swab was taken as a precaution.

"Neither Ms A's clinical notes nor her discharge summary record the nurse's observation of pus spots... There is no record of any observations of the PIVC site, Ms A's arm, or the substance seen on Ms A's arm, or of any discussion with [her mother] about whether her daughter's arm was infected or whether she needed antibiotics. In addition, [a nurse] did not record that he had taken a swab and sent it to the laboratory."

She was discharged to catch a flight. There was disagreement between the mother and medical staff as to whether the woman was given advice about seeking medical help were there to be any more pus or soreness.

The swab test results were finalised the following day, showing "heavy growth of staphylococcus aureus".

The woman lived outside of Auckland, so her GP could not check the swab results on a digital system used by Auckland DHB. Had her GP been in Auckland they could have immediately seen the test results. Instead the results were not seen by any Auckland DHB staff until the next evening, once the woman had already been admitted urgently with an infection.

"Dr J assessed that Ms A needed urgent care, and she was taken by ambulance to [hospital], where she arrived at 1.50pm. Medical staff diagnosed Ms A with septicaemia and prescribed high doses of both vasopressors and antibiotics. However, Ms A deteriorated rapidly and, sadly, she died at 9.20am [the following day] following a cardiac arrest caused by septicaemia."

Auckland DHB commissioned a Root Cause Analysis after the event. It told the HDC it communicated the lessons to staff, changed its guidelines to state people should not go home with a catheter in, and recommended an appropriate length of time for them to remain in.

"On behalf of Auckland DHB, I would like to say how sorry I am for the tragic outcome of [Ms A's] care. I hope that we can continue to build on what we have done already to improve the care we provide to others to reduce the chance of a similar event occurring in future," the Chief Medical Officer of Auckland DHB said.

The mother "expressed frustration at Auckland DHB staff's failure to heed her or her daughter's concerns at the time, or to document their observations".

Hill said Auckland DHB's care of Ms A was "sub-optimal in several respects".

PIVC [peripheral intravenous catheter] check documentation fell below the standard of care, especially at the time of taking the swab, the report said. All the nurses caring for Ms A omitted to document relevant PIVC observations in the clinical record.

Verbal instructions given to Ms A were not documented either in the clinical record or in the discharge summary.The discharge summary omitted reference to the swab the expected test results, or to notify the GP to follow up test results if consulted by the patient, and the GP was not informed of the test results.

"For these reasons, I find Auckland DHB did not provide services with reasonable care and skill, and breached Right 4(1) of the Code of Health and Disability Services Consumers' Rights."

It has been asked to amend a range of policies, and to confirm these have been implemented with the HDC.

Auckland DHB has been approached for further comment.