Death after DHB’s delays and failures
Arohaina Gilbert was young, fit, a hard worker and a good saver.
She’d spent years working on fishing boats saving enough to travel the world. She’d planned to go overseas late last year. And had Hawke’s Bay District Health Board not failed her, she would probably be there now.
But the DHB did fail her, and on the morning of May 14 last year the 25-year-old Wairoa woman died when she couldn’t breathe, because the medical attention she needed had been delayed, and delayed.
An investigation into Arohaina’s death has led Hawke’s Bay DHB to apologise to her family, and acknowledge that it missed ‘‘several opportunities’’ to prevent her death.
‘‘On reviewing Arohaina’s care there were multiple delays and missed opportunities to review her within a clinically appropriate time frame,’’ the DHB’s chief medical and dental officer John Gommans wrote in a letter to the family.
He told the family there were various reasons for delays. They included:
❚ Arohaina had not been prioritised by the thyroid surgeon until four weeks after referral from her GP, instead of the recommended three. This was partly because a thyroid surgeon was on extended leave and was being covered by a general surgeon who did not have the skills to carry out the surgery Arohaina needed.
❚ Despite her need for surgery being assessed as urgent on March 28, she did not get an appointment until May
9.
❚ Later in March, an endocrinologist visiting Wairoa for his clinic saw the CT scan and wrote a letter to the surgical department saying Arohaina needed more urgent intervention. That letter was not read and no-one in the hospital knew about the urgency.
❚ The May 9 appointment was cancelled when the surgeon had to go to another hospital to perform surgery. A new appointment was set for May 30.
❚ A CT scan done on Arohaina in March was the first indication of a critical narrowing in her airway and that an immediate review was needed. But the scan wasn’t sent to the surgical department. It was only sent to Arohaina’s GP.
❚ On May 11, a GP seeing Arohaina spoke to a surgeon about her deteriorating condition but neither felt she needed acute attention (though they did bring her appointment forward to May 16).
‘‘The combination of all the delays from the time of initial referral on February 28 to the time of planned review and surgery on May 16-17 was very significant (2.5 months),’’ wrote Gommans.
‘‘I am very sorry that the combination of delayed recognition of the degree of the airways compromise and delays in planning for her review resulted in missed opportunities to prevent Arohaina’s untimely death. I am very sorry that nothing we can say or do will bring Arohaina back.’’
Gommans added that the DHB’s systems had changed since Arohaina’s death so this did not happen again. These were around criteria for access and referral systems ensuring no delay in surgeons prioritising clinic appointments.
Arohaina was the second eldest of four siblings and the only girl in the family. Her brother, Te Rangi said the family, who received the report in December, was still very upset about the failings that led to her death.
‘‘We miss her heaps. I can’t tell you how much we loved Aroz and what she meant to our family,’’ he said.
He said the family still struggled to believe the factors that led to her death, and wanted it known how badly the DHB failed and that it never happened to another family.
When Stuff reported on Arohaina’s death last year, a DHB spokeswoman said the board was ‘‘committed to making sure the family feel confident and comfortable with the review process and the subsequent coronial inquiry’’.
‘‘Well we don’t feel that there was any such commitment and we certainly don’t feel confident or comfortable,’’ Te Rangi said.
Yesterday, a DHB spokeswoman said a meeting with DHB specialists and the family was being arranged.
The coroner’s office is looking into Arohaina’s death.