Man died after staff’s faulty care

A man died in a Northland hospital after being transferred out of a ‘‘very busy’’ emergency department because staff wanted to meet a target, a new report shows.

Health and Disability Commissioner Anthony Hill found the Northland District Health Board breached the man’s healthcare rights in the lead-up to his death.

The 73-year-old, identified only as Mr B, was admitted to an unnamed public hospital in 2014 following four weeks of diarrhoea and abdominal pain.

Surgical staff thought his symptoms were caused by the medication he had been taking for his gout, and discharged him after two days.

Six days later, Mr B was readmitted as he was still unwell.

The emergency department was unexpectedly busy and Mr B was not assessed for 35 minutes, Hill’s report showed.

A registered nurse completed a Troponin T test – an indicator for a heart attack – which came back as abnormal and indicative of heart damage.

However, the surgical registrar was not advised of that result.

An electrocardiogram (ECG) – a test that checks for problems with the heart’s electrical activity – was not carried out.

The DHB and the registered nurse acknowledged the test should have been completed.

The report also showed a medical registrar was too busy to review Mr B for 41⁄2 hours and the on-call consultant was otherwise occupied.

It was decided to transfer Mr B out of the emergency department to the surgical ward – a lower acuity ward – ‘‘in order to meet a target’’ which said patients should be transferred out of the emergency department within six hours, Hill’s report said.

It was not discussed with the surgical registrar and occurred without several other important steps being carried out.

The administration antibiotics was also delayed.

Mr B was later reviewed by an intensive care registrar.

Soon afterwards, he told nurses he was cold, and was given a blanket and antibiotics. He continued to deteriorate and died a short time later.

Following his death, he was found to have been suffering from subacute bacterial endocarditis, a type of heart infection.

Hill said there were ‘‘opportunities for further inquiry’’, such as tests or input from a cardiologist, that were missed during Mr B’s first hospital admission.

Hill was critical that Mr B’s Troponin T result was not escalated ‘‘in a timely manner’’, that there was no on-call consultant readily available, and that he was transferred to a lower acuity ward. Hill concluded the DHB failed to provide Mr B with services with reasonable care and skill and had breached the Code of Health and Disability Services Consumers’ Rights.

He also said the DHB should ‘‘remind all staff working in the ED that the transfer and the location the patient is transferred to must be clinically appropriate’’. of