Trevor Flood continues to decline after Auckland hospital's overdose error causes brain injury

A cancer patient who suffered irreversible brain damage after he was given an overdose of morphine while in hospital has continued to decline since the life-altering incident.

"He can't do anything. He can't turn the TV on, change the channel, or use a telephone," Kylie Flood said of her husband Trevor Flood's current condition.

"He's pretty much reliant on caregivers and myself, and our daughter."

Before the accidental overdose in 2019 at Auckland City Hospital, Trevor, of Dargaville, was an active builder who loved fishing, motorbike riding, and socialising.

"Now he does nothing all day. Just sits there and watches TV," Kylie told NZME this week.

"It's almost like a dementia. He forgets things and he'll ask the same question 100 times a day."

While Trevor, now 61, has beaten the throat cancer he had been battling, his cognitive health has deteriorated in the past five years since the brain injury.

Kylie said it would get to a point where he would need to move to a rest home.

"I feel sorry for Trevor ... and I feel sorry for our daughter, who has missed out on these years with her dad."

Kylie spoke to NZME after a decision released by the Human Rights Review Tribunal (HRRT) affirming that Health New Zealand Te Whatu Ora had breached Trevor's rights as a patient.

The matter had been referred to the HRRT by the director of proceedings after the Health and Disability Commissioner (HDC) found system failures at the Auckland District Health Board (ADHB), now Te Whatu Ora Te Toka Tumai Auckland, contributed to the overdose of morphine and a lack of adequate monitoring of Trevor.

The HDC was also critical of a nurse involved in his care.

Te Whatu Ora Te Toka Tumai Auckland told NZME it acknowledged and accepted the HRRT's decision and said it was "deeply sorry" for "the shortcomings" in the care it provided Trevor.

While the HRRT's recent decision does not change anything for the family, Kylie said it has provided them with closure.

"It's making them more accountable for what they've done but it doesn't mean anything different for us as such. I guess it's just closing a chapter.

"It's all done and dusted [the complaints process] and it's just a matter of getting on with everything."

The HRRT has the authority to declare that a health provider has breached the Code of Health and Disability Services Consumers' Rights (the code), which it has done in Trevor's case.

In some cases, it can also order the health provider to stop engaging in the conduct that was part of the claim and make orders relating to compensation.

The Floods, who receive ACC, were not awarded compensation by the HRRT nor were they seeking it.

"When I first complained to the HDC it was not for monetary reasons, it was more just getting accountability for what happened to Trevor."

Kylie said she was angry after the incident but has now moved past that.

"It's our lives now and we can't live in the past," she said.

"We have to keep focusing on what the future holds and keep moving forward."

A code red

Trevor was admitted to Auckland City Hospital's oncology ward in February 2019 for pain and dehydration management after a course of radiation therapy for throat cancer.

He was initially prescribed oral morphine to reduce his pain but, as a result of his symptoms, he was unable to tolerate oral medication.

He was instead given morphine through a syringe driver, a pump that provides continuous delivery of medication.

The morphine infusion needed to be done with constant monitoring of vital signs, including four-hourly checks of the injections to avoid overdosing.

Two days later, the hospital was understaffed and a resource nurse, a nurse who works on different wards when a ward is short-staffed, was called in to work the night shift.

She told the HDC she checked on Trevor at midnight and noted he was asleep and breathing normally but did not take his vital signs.

The nurse checked on him again at 2am, documenting his vital signs, and then performed hourly checks but did not take his vital signs.

She told the HDC that when she saw Trevor at midnight, she checked the pump, which was working, but did not do the full required check due to being busy with other patients. She then checked it at 1.30am and 6am and documented this.

At 6.55am, the nurse noticed he was snoring loudly. She was concerned and left the room to check with the day shift and alert the charge nurse, who called a code red and stopped the syringe driver.

Trevor had low blood oxygen levels and was not responsive. He was moved to the intensive care unit (ICU) where he was treated for opioid narcosis.

He was given another drug to reverse the effects of the morphine, which included respiratory depression.

Trevor was discharged a week later but Kylie noted he began to show signs of confusion, reduced co-ordination and altered speech.

The morphine overdose was later found to have caused him irreversible brain damage, with resting tremors, increased muscle rigidity and limb weakness.

Inadequate care

A few months later, Kylie complained to the HDC.

In February last year, HDC deputy Dr Vanessa Caldwell found the ADHB and the resource nurse had breached the HDC code by failing to provide Trevor with adequate care.

Caldwell found the nurse did not complete all the needed vital checks during the night, contributing to his morphine overdose.

She said the nurse also left Trevor to seek assistance instead of staying with him and undertaking an immediate assessment of his consciousness, breathing, and circulation, and raising the alarm.

In the findings, health experts said there were systemic issues at the ADHB due to a lack of clear policies and guidelines, as well as a stretched workforce, with a ratio of one nurse per nine patients.

Along with several recommendations, Caldwell told the nurse and Te Whatu Ora to formally apologise to Trevor and his family.

Margaret Dotchin, acting group director of operations for Te Toka Tumai Auckland, told NZME that Health NZ has formally apologised to Trevor.

"We continue to recognise the deep and lasting impact our care has had on him and his family," she said.

"In 2023, we accepted the Deputy Health and Disability Commissioner's findings of breach of the HDC Code and the associated recommendations, all of which have been actioned."

Dotchin said several other changes had also been made including improved support for nurses, how opioid medications are delivered to non-palliative patients receiving radiotherapy, and training and guidance.

"We want to reassure the public that we are confident the changes we have made will reduce the chances of an incident like this occurring again."

A friend of the Floods has set up a Givealittle page to help them with ongoing costs related to Trevor's care.

This story originally appeared in the New Zealand Herald.