Botched procedure led to death
Commissioner critical of hospital medical team after man suffered fatal brain injury when tube incorrectly placed
Aman died after he suffered a brain injury caused by a botched intubation procedure in which a doctor inserted a breathing tube into his esophagus instead of his trachea.
The error was not picked up for 15 minutes and due to the lack of oxygen, the man developed a severe hypoxic brain injury and died two weeks later.
The man’s whānau, who described him as a much-loved partner, pāpā and koro, complained to the Health and Disability Commissioner (HDC) that Te Whatu Ora did not provide him with an appropriate standard of care, that he and their whānau were not treated with respect, and that informed consent was not provided before the intubation.
In a decision released yesterday by Dr Vanessa Caldwell, deputy health and disability commissioner, it said the man was taken by his daughter to Hawke’s Bay Fallen Soldiers’ Memorial Hospital (FSMH) emergency department to treat two wounds on his back.
While his clinical notes described him as co-operative, he was also noted as agitated and “not compliant and difficult to manage”.
The decision, which does not name the man or the date he attended FSMH, stated that because the impact of his wounds was unknown, a call was made to perform a series of CT scans to check for internal injuries.
Because of his agitated state, he was provided with anaesthetic medication and intubated.
The anaesthetic team was called to assist and the procedure was performed in the emergency department where the tube was incorrectly placed in the man’s esophagus, leading to the stomach, instead of his trachea, leading to the lungs.
Te Whatu Ora told the HDC that before this event the anaesthetic team had rarely worked in the emergency department, and were less familiar with the environment.
After the error was picked up, a successful intubation took place but by that time, he had already sustained a fatal brain injury.
The man was placed in the intensive care unit for 15 days until his ventilation was removed and he died.
A coroner ruled the direct cause of death was hypoxic ischaemic encephalopathy, with the antecedent cause being “oesophageal intubation”.
Following an investigation into the incident, the deputy commissioner found Hawke’s Bay District Health Board, now Te Whatu Ora Te Matau a Māui, breached the Code of Health and Disability Services Consumers’ Rights.
The breach related to its failure to provide services of an appropriate standard.
Caldwell adopted the findings of Te Whatu Ora’s Adverse Event Review (AER) and was critical that the medical team failed to recognise the esophageal intubation in a timely manner.
The AER stated the man’s death was not from the esophageal intubation but from failure to recognise esophageal intubation until after a significant time had elapsed.
“Oesophageal intubation occurs not infrequently, but early recognition of corrective action prevents this being a major problem, and usually has no clinical consequence,” the AER stated.
“Intubations performed in the [ED] have a significantly higher rate of adverse outcomes and important deficiencies of airway management compared with those performed in routine anaesthetic practice.”
In her decision, Caldwell identified several factors that contributed to the man’s death, including a lack of standardised equipment, superior equipment not being made available and staff members believing that certain equipment was not functioning properly.
“I am critical that Te Whatu Ora did not ensure that there was suitable equipment for difficult airway management available in the ED, and that there was a lack of standardised equipment across the hospital,” she said.
“I am also critical that the staff were not made aware of the equipment that was available, and that the staff were not reassured that the equipment was functional and being maintained adequately. In my view, this contributed to the delay in diagnosing the oesophageal intubation.”
In response to concerns raised by the man’s whānau about consent not being obtained before the procedure, Caldwell noted that given the emergency situation, the decision to intubate was necessary and in the circumstances, it was reasonable that his consent could not be sought at the time.
Caldwell recommended Te Whatu Ora provide a written apology to the man’s whānau and put in place regular training for all current staff in the emergency department and intensive care unit on the standard practice in emergency airway management.
She also acknowledged the significant impact these events have had on the man’s whānau and recommended Te Whatu Ora provide them with the opportunity to have a hohou te rongo, a restorative practice, facilitated by HDC’s cultural team.
In their complaint to the HDC, the man’s whānau said they felt the hospital had impeded their ability to support the man, that they felt unwelcomed and unsupported by staff, and claimed the hospital made it difficult to facilitate karakia.
Te Whatu Ora, Hawke’s Bay accepted the HDC’s findings and acknowledged it should have done better for the man and his whānau.
“Our deepest sympathies are with the whānau for their loss,” Dr Benjamin Pearson, the group’s chief medical officer, said in a statement to NZME.
“We take patient safety and wellbeing extremely seriously, and no harm or distress to a patient under our care is acceptable.”
Pearson said an apology had been made to the man’s whānau in person and in writing, and the hospital group welcomed the opportunity for a hohou te rongo so the whānau could achieve a meaningful resolution.
He said a robust AER had taken place since the man’s death and the group has been subject to a Coroner’s Report, which had several recommendations.
“As a result of those reviews, we implemented a range of improvements. These include purchasing a suite of new equipment required for emergency airway access, which has also allowed for the standardising of equipment across the hospital, and implementing a series of checklists which ensures correct procedures are being followed.
“Our teams have ongoing training for emergency airway management and various emergency simulations.”
Pearson said it would report to the HDC on the effectiveness of its training and review its practices bimonthly through a committee.