FA­TAL EN­COUNTER

The death of a man ad­mit­ted to an un­der-fire hos­pi­tal for mi­nor surgery throws a spot­light on com­mu­ni­ca­tion is­sues.

New Zealand Listener - - MEDICAL MISADVENTURE - By DONNA CHISHOLM

Brian Davies was in­jured falling from a lad­der at his home. He died falling through the cracks at a be­lea­guered hos­pi­tal. It’s a bit­ter irony, his fam­ily say, that Davies, 78, was such a de­tails man. The for­mer dairy con­sul­tant was a fas­tid­i­ous note taker, a dili­gent plan­ner and a skilled communicator; some of the hos­pi­tal staff who cared for him ap­par­ently were not.

The Health and Dis­abil­ity Com­mis­sioner (HDC) has launched a for­mal in­ves­ti­ga­tion into the death of Davies five days af­ter he suf­fered a pul­monary em­bolism dur­ing what should have been rou­tine surgery at Mid­dle­more Hos­pi­tal in Auck­land in April 2017. Fewer than 5% of com­plaints to the com­mis­sioner re­sult in for­mal in­ves­ti­ga­tions.

The hos­pi­tal has been at the cen­tre of a num­ber of con­tro­ver­sies in the past year, most in­volv­ing run­down build­ings with mould, as­bestos and raw sewage is­sues, but also un­ap­proved spend­ing on some build­ing con­tracts. In April, it was de­scribed as “the em­blem of what is wrong with New Zealand’s health­care sys­tem”. Last year, po­lice in­ves­ti­gated the 2013 death of pa­tient Heather Bills af­ter a “non-ac­ci­den­tal” dose of in­sulin ad­min­is­tered by a nurse.

De­spite his wound be­ing as­sessed as re­quir­ing surgery within 24 hours of ad­mis­sion, Davies waited al­most a week for doc­tors to de­bride an in­fected haematoma on the back of his right calf af­ter com­mu­ni­ca­tion broke down be­tween the hos­pi­tal’s or­thopaedic and plas­tics teams. His fam­ily say team mem­bers had heated ar­gu­ments in front of him about who should do the op­er­a­tion. The hos­pi­tal has con­firmed to the fam­ily that his surgery was not de­layed by more acute cases and ac­knowl­edged a “tem­po­rary mis­com­mu­ni­ca­tion”, say­ing “there were a num­ber of ar­eas dur­ing Mr Davies’ care where com­mu­ni­ca­tion and doc­u­men­ta­tion could be im­proved.”

The de­lay, dur­ing which he was largely im­mo­bilised in a leg brace with his an­ti­clot­ting medicine with­held be­cause of the pend­ing surgery, put him at high risk of ve­nous throm­boem­bolism (VTE). But he was given no doc­u­mented clot as­sess­ment, and no pre­ven­tive ther­apy, un­til two days be­fore his op­er­a­tion, when it’s likely the em­bo­lus had al­ready formed in his leg, from where it trav­elled to his lungs.

The hos­pi­tal has apol­o­gised to Davies’ fam­ily for an ex­pe­ri­ence which “added to their dis­tress”, and says it has taken steps to en­sure clear path­ways of com­mu­ni­ca­tion are es­tab­lished and ac­cu­rately doc­u­mented af­ter a con­sul­ta­tion. The fam­ily say they’re go­ing pub­lic to draw at­ten­tion to is­sues they be­lieve are deep-seated in the pub­lic hos­pi­tal sys­tem. “Brian should be with us to­day be­cause he was healthy and looked af­ter him­self,” his widow, Ca­role, told the Lis­tener. “His death was un­nec­es­sary and tragic and we can’t do any­thing about it, but we can per­haps stop it hap­pen­ing to some­body else.

“Hind­sight is a won­der­ful thing, and on re­flec­tion, we should have made a fuss ear­lier. But be­cause we are rea­son­able, av­er­age folk, and our med­i­cal knowl­edge was only av­er­age, you don’t know what you don’t know.”

FIRST AD­MIS­SION

She sus­pects he was the vic­tim of a “per­fect storm” of cir­cum­stances: ad­mit­ted on Easter Satur­day dur­ing a hol­i­day week­end, to a busy hos­pi­tal braced for the start of the flu sea­son. CEO Geraint Martin had re­signed to take up a po­si­tion at Te Papa and Ca­role Davies be­lieves there was a “lead­er­ship vac­uum” that meant although poli­cies were in place, they weren’t nec­es­sar­ily fol­lowed.

The hos­pi­tal ad­mis­sion that led to Davies’ death was his sec­ond that month. A fit and ac­tive man who was a prop­erty de­vel­oper in re­cent years, Davies had been on dabi­ga­tran, a blood-thin­ning agent, for a num­ber of years be­cause he had atrial fib­ril­la­tion, a rhythm ab­nor­mal­ity in the heart that can cause clots, but was oth­er­wise well. He’d been fix­ing a cracked board near the roof on his Clarks Beach home in the late af­ter­noon of April 1 when the lad­der shifted and top­pled. He fell about 2m, land­ing through the rungs, tear­ing the quadri­ceps mus­cles in his thigh and lac­er­at­ing his shin from knee to an­kle. He hob­bled to bed in pain that night, but the next day Ca­role drove him to the lo­cal emer­gency clinic, which re­ferred him to Mid­dle­more.

The hour-long surgery on April 3 to re­pair the quad mus­cle and stitch the cut was un­event­ful and he was dis­charged, wear­ing a leg brace, two days later. Ca­role Davies says they were told to come back in two weeks for the stitches to be re­moved, but apart from that, were given no care plan, and no district nurs­ing help was ar­ranged. “I had no idea what to do,” she says. Brian Davies com­plained to ACC, and later to an or­thopaedics regis­trar at Mid­dle­more. “My neigh­bour, who’s a nurse, said, ‘This is ridicu­lous’, and or­gan­ised a district nurse to visit,” Ca­role says. The nurses changed his dress­ings, but nei­ther they nor the fam­ily took much no­tice of a small scrape on the back of his calf, at the lower end of the brace, un­til faint red lines be­gan ra­di­at­ing from it, in­di­cat­ing in­fec­tion had set in. He was

Team mem­bers had heated ar­gu­ments in front of him about who should do the op­er­a­tion.

read­mit­ted to Mid­dle­more on April 15.

GROW­ING FRUS­TRA­TION

Davies was kept “nil by mouth” most morn­ings in prepa­ra­tion for surgery that didn’t hap­pen – the or­thopaedic sur­geon in charge of his case thought plas­tics should do the op­er­a­tion, but when an or­thopaedic regis­trar tried to con­tact a plas­tics regis­trar by phone, the per­son couldn’t be con­tacted be­cause they were on sick leave. Nurs­ing staff made re­peated ref­er­ences to the de­lays in his notes on suc­ces­sive days: “needs plas­tics in­volve­ment”, “await­ing plas­tics re­view”, “plas­tics to see(!)”, “for plas­tics in­put” and “pa­tient frus­trated about plas­tics”. Fi­nally, on April 20, the sixth day of his read­mis­sion, they note an “acute plas­tics re­view” and the op­er­a­tion – by a plas­tic sur­geon – was fi­nally car­ried out the fol­low­ing day.

Davies’ daugh­ter, Kim Davies-Hay­cock, who has led the fam­ily’s en­gage­ments with

The or­thopaedic sur­geon thought plas­tics should do the op­er­a­tion but the plas­tics regis­trar couldn’t be con­tacted. Nurs­ing staff made re­peated ref­er­ences to the de­lays.

the Coun­ties Manukau District Health Board, says her fa­ther told them mem­bers of the or­thopaedic and sur­gi­cal teams had heated dis­agree­ments within his earshot about who should do the op­er­a­tion. “One of them said words to the ef­fect, ‘I’m not f---ing re­spon­si­ble.’” Her fa­ther told them the or­thopaedic sur­geon was aloof and not easy to com­mu­ni­cate with.

Ca­role Davies says her hus­band told her the two teams were “at each other” about who should op­er­ate on the wound, about 3-4cm in di­am­e­ter. She was present dur­ing one “cross” ex­change, on about the third day of his hos­pi­tal­i­sa­tion. “One said, ‘Well, who’s go­ing to be do­ing this then?’ And Brian’s ly­ing on the bed and I’m sit­ting there think­ing, ‘You don’t re­ally ex­pect to hear this in hos­pi­tal.’ But I wasn’t privy to who was talk­ing to whom be­cause they don’t wear name tags. In hind­sight, you think, ‘Why didn’t I make a fuss about it?’ Why didn’t I say, ‘What the hell is go­ing on here?’”

Davies was with­out any ther­apy to pre­vent clot­ting for five days. Mid­dle­more says the or­thopaedic sur­geon ac­knowl­edged Davies had risk fac­tors for a deep vein clot, but said there were also in­di­ca­tions for not us­ing pro­phy­lac­tic treat­ment. These in­cluded the fact he was “mo­bile” – which the fam­ily say he was not – and con­cerns about fur­ther in­fec­tion, wound-ooze and bleed­ing from his haematomas. Those rea­sons are not doc­u­mented in his notes. Davies-Hay­cock says she had no idea how vi­tal it was for her fa­ther to keep his legs mov­ing while he was bedrid­den.

The health board, in a re­sponse to a re­quest for com­ment from the HDC, says the or­thopaedic sur­geon “ac­cepts that the doc­u­men­ta­tion of deep vein throm­bo­sis pro­phy­laxis and de­ci­sions has not been done well in Mr Davies’ case”. It apol­o­gised for the de­lay to his surgery, and that rea­sons for it weren’t con­veyed clearly to the fam­ily, in­clud­ing that an­tibi­otics were needed be­fore de­bride­ment surgery. The health board re­fused to dis­cuss the case with the Lis­tener, say­ing this was inap­pro­pri­ate while it was still un­der HDC in­ves­ti­ga­tion.

Ca­role says her hus­band had com­plete faith in the hos­pi­tal staff. “If they said, ‘This is how we are do­ing it’, that’s how it was. He trusted them; they were the pro­fes­sion­als. It was an old-fash­ioned sort of thing. Whereas I might want to ques­tion it, Brian was al­ways, ‘They know a whole lot about stuff that I don’t know about.’” Some morn­ings, she would have to go to the nurses’ sta­tion to seek food, she says, be­cause he hadn’t been fed af­ter the op­er­a­tion was post­poned yet again. “He said, ‘Don’t make a fuss, it won’t hurt me to lose a bit of weight.’”

SEC­OND AD­MIS­SION

“In hind­sight, you think, ‘Why didn’t I make a fuss?’ Why didn’t I say, ‘What the hell is go­ing on here?’”

Brian Davies’ hos­pi­tal notes record he was “handed over to theatre nurse” at 11.05am on Fri­day, April 21. Ca­role knew the pro­ce­dure was fairly mi­nor, and ex­pected it to take only about 20 min­utes. She was so re­laxed about it, she went shop­ping – she’d told him on the phone that morn­ing she’d visit when he woke up.

The plas­tic surgery team was ap­ply­ing dress­ings af­ter the op­er­a­tion, at 12.35pm, when Davies showed the first signs of a mas­sive pul­monary em­bolism. His blood pres­sure and car­diac out­put be­gan to drop pre­cip­i­tously. Hos­pi­tal notes record the in­creas­ingly fran­tic ef­forts to re­vive him, in­clud­ing doses of adrenalin and clot-bust­ing drugs and six rounds of car­diopul­monary re­sus­ci­ta­tion. At 1.38pm, Davies, on life sup­port, was trans­ferred from theatre to in­ten­sive care.

Ca­role doesn’t re­mem­ber who called her or when, only that there was “a pan­icked phone call from a man at the hos­pi­tal, who said, ‘Get in here straight away and bring some­one with you.’” Un­able to raise the rest of the fam­ily, she bat­tled Fri­dayafter­noon mo­tor­way traf­fic alone to get to Mid­dle­more. “All I could think was, ‘It can’t be that bad. It can’t be that bad.’”

It was very much worse. “Some­one took me to ICU and there’s my dar­ling ly­ing co­matose, with stuff at­tached ev­ery­where. I was so shocked. I thought I’d be bring­ing him home. I was in a state of dis­be­lief. It hadn’t even oc­curred to me that this could hap­pen. They were go­ing to clean out a wound. It was mi­nor surgery. That’s why I was so ill-pre­pared for it.”

For a brief time in the next few days, Davies, sur­rounded by his fam­ily, looked as

if he might rally. His se­da­tion was re­duced; he started to squeeze their fingers when they held his hand and wig­gle his toes on com­mand. “He was in­tu­bated, so he couldn’t com­mu­ni­cate with us,” Davies-Hay­cock says. But his in­creased con­scious­ness came with a dis­tress­ing side ef­fect. “It looked like he was in agony; he was silent scream­ing, with aw­ful gri­maces.” The se­da­tion was in­creased again, so up­set­ting was it for fam­ily and staff. In the fol­low­ing days, Davies’ limbs swelled hor­rif­i­cally as his or­gans shut down. On April 26, a CT scan showed he had sus­tained ex­ten­sive brain dam­age in a mas­sive stroke 48 hours ear­lier.

Davies-Hay­cock and her mother drove to the Parnell Rose Gar­dens and talked about let­ting him go. They spent his last night with him, play­ing his favourite mu­sic – Leonard Co­hen, Bread, Ca­role King, a bit of Men­delssohn, some Gre­go­rian chants. They sang You Are My Sun­shine and told him how much they loved him. Maybe he heard. When he died, at 3.15pm on April 27, it was, his notes say, a calm and peace­ful death.

In the months af­ter her fa­ther’s death, Davies-Hay­cock says, it looked as if hos­pi­tal man­age­ment re­ally wanted to do the right thing. On Au­gust 14, a week af­ter the fam­ily laid a com­plaint with the HDC, they met the health board’s act­ing chief ex­ec­u­tive, Dr Glo­ria John­son, and chief med­i­cal of­fi­cer, Dr Vanessa Thorn­ton, who said they would set up a task­force of se­nior or­thopaedic, nurs­ing and phys­io­ther­apy staff to en­sure “gold stan­dard” as­sess­ment of ve­nous throm­boem­bolism (VTE) for all acute pa­tients, and in­vited Davies-Hay­cock to join it. Davies-Hay­cock spent weeks look­ing into in­ter­na­tional best-prac­tice, but at the next meet­ing, on Septem­ber 18, her hopes were dashed. There would be no task­force; in­stead, they had a plan to re­place the in­ad­e­quate and un­used VTE as­sess­ment sheets and re­mind staff to do the as­sess­ments. They would now put a sticker on each pa­tient’s file.

In De­cem­ber last year, Davies-Hay­cock met the or­thopaedic sur­geons un­der whose care her fa­ther was ad­mit­ted. It wasn’t the heal­ing meet­ing she’d hoped for. “I told the sur­geon that I’d never heard him say to us that he was sorry. He said, ‘I’d like you to

Her hus­band had com­plete faith in the hos­pi­tal staff. “He trusted them: they were the pro­fes­sion­als.”

know I’m sorry’, but it means noth­ing when you have to tell some­one to do it.”

She says many or­gan­i­sa­tions, in­clud­ing those in the trans­port and con­struc­tion in­dus­try, must com­ply with oc­cu­pa­tional health and safety guide­lines, but in hos­pi­tals, there ap­pears to be no sim­i­lar en­force­ment. “Why can se­nior doc­tors dis­re­gard writ­ten pol­icy for VTE and no one is held ac­count­able?”

VTE pre­ven­tion is a fo­cus of the HQSC’s safe surgery group, led by Uni­ver­sity of

Auck­land pro­fes­sor of surgery Ian Civil. About 2000 pa­tients a year have a VTE in hos­pi­tal, a third of which are pul­monary em­boli. About 60 pa­tients a year die. Civil says they can oc­cur even when ev­ery­thing pos­si­ble is done to pre­vent them, but when they hap­pen – and are fa­tal – in the ab­sence of steps to pre­vent them, “it is hard to de­fend”.

When pa­tients on an­ti­co­ag­u­lants are ad­mit­ted for surgery, they’re usu­ally with­drawn from those drugs ahead of the op­er­a­tion, be­cause of the risk of bleed­ing, and ei­ther given an al­ter­na­tive, shorter-act­ing drug such as clex­ane, or VTE pro­phy­laxis such as com­pres­sion stock­ings, foot pumps, or in­ter­mit­tent com­pres­sion de­vices that mimic nat­u­ral calf con­trac­tions. Civil says ev­ery pa­tient should have a VTE plan doc­u­mented for them and, with­out spe­cific con­traindi­ca­tions, have a “multi-modal” strat­egy in place. “Most of us are a bit ag­gres­sive on our VTE pro­phy­laxis – lit­er­ally, ev­ery­one gets some­thing.”

The re­sults of an ag­gres­sive ap­proach have been pos­i­tive, he says, with in­ci­dence rates of deep vein throm­bo­sis – which de­scribes a range of blood clots, in­clud­ing VTE – falling from about four years ago, when the HQSC be­gan work­ing with district health boards on a pre­ven­tion pro­gramme. The HQSC pre­dicts VTE oc­curs in about 1% of acute sur­gi­cal ad­mis­sions, and about 1% of those are fa­tal. It es­ti­mates that since Jan­uary 2013, more than 350 pul­monary em­boli have been avoided, sav­ing $7.3 mil­lion and likely dozens of lives.

DEL­E­GATED COM­MAND

But Civil says pre­ven­tion poli­cies can only take the health ser­vice so far. More im­por­tant is the com­mu­ni­ca­tion that en­sures pa­tients are re­ceiv­ing co-or­di­nated care. A com­mon prob­lem, il­lus­trated in the Davies case, is that de­ci­sion-mak­ing is of­ten del­e­gated by de­fault to ju­nior peo­ple. When the or­thopaedics team wanted the plas­tics team to re­view and op­er­ate, a regis­trar was del­e­gated to set that up by phon­ing an­other regis­trar, but when that doc­tor was sick, the mes­sages went unan­swered.

A for­mer army sur­geon, Civil says that in the mil­i­tary, “you al­ways have the most se­nior peo­ple mak­ing the most im­por­tant de­ci­sions. Is this per­son sick or not? Should this per­son have an op­er­a­tion or not? Should this per­son go home or not? You get the se­nior peo­ple to make those de­ci­sions and the less se­nior peo­ple to do it. In the health sys­tem, we seem to have the re­verse

“It looked like he was in agony: he was silent scream­ing, with aw­ful gri­maces.” A CT scan showed he had sus­tained ex­ten­sive brain dam­age.

phi­los­o­phy. Calls from GPs, who are of­ten very ex­pe­ri­enced, are taken by the most ju­nior mem­bers of staff, who can act like a wall and give them the third de­gree about what they’ve done or not done and maybe send it to an­other spe­cialty. A se­nior per­son would say, ‘Send them in, we’ll sort it out for you.’ If a con­sul­tant calls me up, I’m go­ing to specif­i­cally do some­thing, whereas let­ting ju­nior peo­ple talk to other ju­nior peo­ple, it can get lost in trans­la­tion.”

Two se­nior doc­tors who’ve seen de­tails of the case but did not want to be named called Brian Davies’ treat­ment “very poor”. One said the notes por­trayed “com­plete dys­func­tion­al­ity” of the med­i­cal teams. “Things like this re­ally an­noy me,” he said. “Peo­ple didn’t talk to each other at a high level, and weren’t pa­tient-fo­cused. When I come in to hos­pi­tal, I want some­one look­ing af­ter me that I can rely on to have my in­ter­ests at heart and in this I can’t see that any­one was to­tally re­spon­si­ble.

“There was end­less del­e­ga­tion – del­e­ga­tion up and down within the or­thopaedic team, del­e­ga­tion of ju­nior peo­ple to call plas­tics. No one said, ‘If this was me and I was Mr Davies and I had fallen down a lad­der, what would I want to have hap­pen? I know darn well what I would want and I don’t see it hap­pen­ing in these notes.”

“They didn’t recog­nise what a high risk he was for a VTE,” said the sec­ond doc­tor. “Sur­gi­cal ser­vices tend to be very fo­cused on op­er­at­ing and don’t nec­es­sar­ily have the skillset to man­age the prob­lems of some­one of this pa­tient’s age.”

In some other hos­pi­tals, el­derly peo­ple ad­mit­ted with frac­tured fe­murs are trans­ferred im­me­di­ately af­ter surgery to the older peo­ple’s health ser­vice. “If I ran the place, the sur­geons would do the sur­gi­cal bit but wouldn’t be re­spon­si­ble for the day-to-day care.”

Brian Davies would have turned 80 on July 7 this year. He’d have felt cheated at miss­ing the mile­stone birth­day, Ca­role reck­ons. The fam­ily are still strug­gling with the gap he has left. “Some­times there doesn’t seem a lot of point in life when the love of your life is dead. If he’d died from nat­u­ral causes, I would have been pre­pared for it. For God’s sake, we all know we are go­ing to die. He would have said, ‘Well, I had a re­ally good in­nings’. But he would have been bloody an­noyed that he hadn’t been prop­erly looked af­ter.”

“The sur­geon said, ‘I’d like you to know I’m sorry’, but it means noth­ing when you have to tell some­one to do it.”

Ca­role and Brian Davies with grand­daugh­ters, from left, So­phie Hay­cock, Bella Davies, Ge­or­gia Davies and Grace Davies.

Speak­ing up: Kim Davies-Hay­cock and Ca­role Davies.

Fam­ily por­trait: back row, from left, Grace Davies, Michael Davies, Jake Hay­cock, Kim DaviesHay­cock, Matt Hay­cock, Ca­role Davies, Craig Hay­cock. Front row, Oskar Davies, Ge­or­gia Davies, Brian (hold­ing his dog Poppy), So­phie Hay­cock, Bella Davies, Dianne Davies, Jan Davies.

Ian Civil, head of the HQSC’s safe surgery group.

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