Criticism over patient’s care
A coroner has criticised the Canterbury District Health Board (CDHB) for its care of 28-year-old man before he died of a heart attack.
West Coast farmhand Bryan Joseph Edmonds was found unconscious by a workmate in a farm paddock on July 14, 2017. He could not be revived by emergency services.
The father-of-two was the fourth sibling in his family to die of a heart-related issue.
Coroner David Robinson released a report into the Whataroa man’s death yesterday.
He said cardiac issues were identified before Edmonds’ death, but health professionals did not investigate them in any detail.
An autopsy found Edmonds died suddenly due to hypertrophic cardiomyopathy, a condition that was in his family history.
The coroner said Edmonds had two abnormal electrocardiograms (ECGs) after he was admitted to Christchurch Hospital with appendicitis in July 2014.
He was advised to see his GP for further investigation.
‘‘There is no evidence of
aSue Nightingale, CDHB chief medical officer
referral to a cardiologist and the findings were not reported to the general practitioner . . . there is no evidence of a discharge summary having been prepared,’’ the coroner said.
The CDHB said a clerical error meant Edmonds was recorded as being a patient of Bulls Medical Centre instead of Buller Medical Centre.
‘‘There was therefore no follow-up of the abnormal ECG report, save for the verbal advice,’’ the coroner said.
Edmonds went to Buller Medical in May 2015 complaining of occasional blackouts and chest pain. The coroner said it was ‘‘troubling’’ the GP did not review the ECG notes. The CDHB told the coroner the notes would have been ‘‘there to be seen’’.
The doctor ordered a chest X-ray, but there was no record it had been done.
The coroner could not say whether further investigation into Edmonds’ condition would have saved his life, but his care ‘‘would have been improved’’ if the abnormal ECG had been followed up and the X-ray carried out.
‘‘An admitted history of a prior heart murmur coupled with an apparent family history of sudden cardiac death (though not known to Canterbury District Health Board) plus the abnormal ECG would in my view have warranted follow up.’’
The CDHB’s reporting processes were also ‘‘wanting’’, he said. ‘‘No discharge summary was ever prepared. That is evidence of a lack of continuity of care which could have denied the general practitioner relevant information. That the wrong GP was identified on the CDHB records indicates a further difficulty in follow up information being properly communicated.’’
The coroner recommended the CDHB review its procedures.
He initially wanted to recommend that all abnormal ECG be referred to a cardiologist but accepted the CDHB’s response that it would not be ‘‘feasible or desirable given resources’’.
CDHB chief medical officer Sue Nightingale said the board accepted the coroner’s findings.
‘‘We express our sympathies to the family of Bryan Edmonds. We also acknowledge that our reporting and administration processes were wanting in this instance,’’ she said.
‘‘We would like to reassure the public that we have made changes to improve our processes to reduce the chances of an incident like this occurring again. At that time in 2014, our systems were not as robust as they are now.’’
The changes included providing admitting staff with better access to patient records, allowing general practices to update hospitals when a patient transferred from one GP to another, and GPs being able to view discharge summaries for their patients.
The Edmonds family has been approached for comment.
‘‘We would like to reassure the public that we have made changes to improve our processes to reduce the chances of an incident like this occurring again.’’