Hospital error led to death of shot man

A man died in Hawke’s Bay Hospital after staff put oxygen into his stomach instead of his lungs, partly due to ‘‘confusion’’ within the team treating him.

Nevara Raheke died in the hospital on December 1, 2017 – two weeks after being admitted for two gunshot wounds to his back. A recently released coroner’s report found Raheke died because a breathing tube was incorrectly placed into his oesophagus instead of his trachea, or airway, meaning he was not receiving any oxygen. Raheke, 47, was shot by a man who found him and two accomplices robbing and beating a man at a property in Central Hawke’s Bay on November 17, 2017.

Raheke received two shots from a .22 firearm to the back. His accomplices drove him to hospital in Hastings.

Coroner Peter Ryan said Raheke was treated as a highest priority by the hospital. He was initially awake and sitting upright but was not speaking and was taking very shallow breaths. He was also highly agitated.

Staff decided to sedate Raheke and to intubate him, meaning a tube was to be inserted into his trachea to provide oxygen. Initial checks appeared to confirm the tube was in the correct place, although no carbon dioxide was detected.

The tube was adjusted and a second monitor used but this also did not detect carbon dioxide. So staff put a fibre-optic scope down the tube.

That revealed the tube had not gone down Raheke’s trachea but his oesophagus – which leads to the stomach.

The tube was correctly positioned but he had gone 23 minutes without oxygen.

He was expected to have a severe brain injury as a result. His condition did not improve and, after 15 days, the tube was removed and he died.

A pathologist found traces of cannabis, methamphetamine and amphetamine in Raheke’s blood, and while those may have caused his agitated state, it was the lack of oxygen that caused his death.

The gunshot wounds did not cause his death, she said, though the coroner added ‘‘it is important not to lose sight of the fact that if Nevara had not been shot then he would not have been placed in the lifethreatening position he was in’’.

Following his death, Hawke’s Bay DHB conducted an adverse event review.

This found that if the incorrect placement had been discovered sooner it could have been corrected sooner.

It also found there was confusion in the team treating Raheke over who was in charge of his airway. The team itself noted a lack of communication.

It was noted that had Raheke arrived at hospital via ambulance, the emergency department would have been forewarned about his condition.

A number of recommendations were made following the DHB’s review.

Ryan endorsed those and did not make any further comment.

Hawke’s Bay DHB spokesman Robin Whyman said Raheke’s presentation was ‘‘complex’’ and the staff involved had been ‘‘deeply affected’’ by the case.

‘‘A number of reviews and investigations into this case has seen the DHB implement changes, including undertaking more staff training with regular simulation of difficult patient presentations.

‘‘Our deepest sympathies are with the Raheke wha¯ nau and . . . we have apologised to them in person,’’ Whyman said.

The man who shot Raheke stood trial last year for wounding with intent to cause grievous bodily harm. The charge was discharged and the man’s name was permanently suppressed.