Infected foot turns deadly

The death of an elderly man in Palmerston North Hospital from an infected foot was partly due to shortcomings in his care by the district nursing service, a coroner has found.

Coroner Carla na Nagara said some aspects of Edward John Brownlee’s care were not as good as they might have been.

She cited a delay in recognising how unwell the 78-year-old, from Levin, was in 2014 and problems with the thermometers nurses used.

In findings released yesterday, na Nagara said Brownlee was referred to the nursing service for treatment after he refused to go to hospital, which his doctor had suggested.

This resulted in his referral to the nursing service.

Thermometers were used twice during his treatment – readings the first time were put down to a faulty thermometer and the second time two were used, but neither produced a reading.

On the second time, July 4, 2014, Brownlee’s condition appeared to be worse, an ambulance was called and he died in hospital the next day.

Na Nagara said a Midcentral District Health Board investigation into Brownlee’s death found the main contributor to the delay in his treatment by the nursing service was the lack of available thermometers, with nurses having to supply their own.

A duplication and mix-up of notes meant it was difficult to get a good picture of events, and there was a lack of follow-up.

Na Nagara said as a result of Brownlee’s death, changes were made to the processes of the nursing service and provision of equipment – including thermometers in each district nurse car.

She said because of Brownlee’s ‘‘considerable underlying medical problems’’, it was not possible to know whether he would have survived the infection if his care had been better and nor could it be said that the care he did receive caused his death. ‘‘However, it is reasonable to suggest that his chances of surviving the infection were reduced due to the shortcomings in the care he received.’’

She said she was satisfied the health board had taken the appropriate steps in response to the identified shortcomings.