The woman underwent surgery but developed sepsis the day before she was scheduled to go home. Photo: RNZ / Nate McKinnon
An investigation has found a woman who developed sepsis did not receive an acceptable standard of care following surgery at Dunedin Hospital.
The woman underwent surgery to repair a fracture but developed sepsis the day before she was scheduled to return to her home country on 1 August, 2019.
It took more than 10 hours from when blood tests were requested and returned with abnormal results for treatment to be provided.
The Health and Disability Commissioner found the Southern District Health Board breached the woman's right to have services provided with reasonable care and skill - Right 4(1) of the Code of Health and Disability Services Consumers' Rights.
Deputy Health and Disability Commissioner Deborah James said staff should have postponed her departure earlier than they did, especially as her condition continued to worsen in the lead-up with a fever, an increasingly rapid heart rate, and low blood pressure.
"The woman continued to present as severely septic at the time of handover to the retrieval team at 2.15am on 1 August 2019. The Air Ambulance's medical director declined to transfer the woman as she was too unwell, and requested an urgent review by senior medical staff," James said in her report.
"Given that the woman's condition was continuing to deteriorate, I would have expected the clinical staff to have postponed the repatriation earlier than they did. In my view, the repatriation should have been cancelled at 10.00pm, when it was clear that the woman's condition was unstable and not improving."
The woman was treated for sepsis in intensive care between 1 and 5 August.
Deborah James found staff failed to obtain the full clinical picture, did not appreciate the risks involved in trying to proceed with the repatriation, and did not take the appropriate and required actions when her condition worsened.
The case also highlighted the importance of identifying sepsis and taking appropriate actions when the condition of a patient deteriorates, she said.
The woman also raised concerns about the clinical documentation on her case.
"She is described in the notes as 'difficult and controlling', and 'childlike and attention-seeking'. The clinical documentation also states that the woman was 'acting weird... annoying behaviour'," James said.
"SDHB accepted that the wording used in the clinical documentation was unprofessional. It explained that the nurses who recorded these entries in the clinical notes did so in an attempt to describe the behaviour they had observed, but that the descriptions may not have been accurate owing to English being their second language."
The Southern DHB has advised the Commissioner that it has since made changes, including additional training for staff.
Deborah James made further recommendations, including the DHB providing a formal written apology to the woman, developing guidelines for identifying sepsis and managing patients with sepsis symptoms, provide all nursing staff involved with training on documentation, and using this report as part of staff learning at the board.
Te Whatu Ora Southern chief medical officer David Gow said Southern Health had apologised to the woman for the distress caused to her and her family.
"We pride ourselves on delivering a high standard of care and we are very sorry that our systems and processes failed this patient," he said.
"We are working through the commissioner's recommendations - all of which we accept and will implement as part of our ongoing commitment to improving the quality of our care.
"Since this incident occurred, changes to our practice have been made and we would like to reassure the patient, their family, and our community that these changes will reduce the chances of our systems and processes failing again."
That included presentations to the surgical ward nurses on sepsis recognition and further education on the deteriorating patient focusing on sepsis.
All ward nursing staff were required to undertake the online Early Warning Score education package and attend an eight-hour deteriorating patient study day, he said.
Southern Health audits the use and escalation of the Early Warning Score monthly as required by the Health Quality and Safety Commission.
