Coroner: Better processes needed

A coroner is recommending processes be developed to ensure blood culture results are documented as being provided and received by the treating team following an investigation into a woman’s death at Waikato Hospital.

Tonette Avis Laing, 64, from Tairua, died of multiple-organ failure due to sepsis on August 22, 2018, a recently released report from Coroner Michael Robb said.

Laing was first admitted to hospital on June 5, with suspected pancreatic cancer, and investigations identified narrowing of her bile duct and, as a result, a stent was inserted.

During this admission there were indications of infection and a possible septic episode, which is something that can occur as a result of a stent procedure.

On July 1 there was a further suspected septic episode, leading to antibiotics being administered until July 3. Laing rallied and on July 11 she was discharged to hospice care, before being discharged home in mid-July. But a short time later Laing developed sepsis and was admitted into hospital again.

On July 27 her clinical notes stated a plan for continuing intravenous antibiotics, and for contact to be made with the infectious diseases team in respect of an oral alternative.

There was reference to an email being sent to the team, but the contents of that email and any response did not form part of the clinical notes, and there was no other documentation available.

By August 17, Laing’s deterioration was clear and there were no viable treatment options. She was transitioned to comfort care and died on August 22.

Dr Metcalf provided an expert opinion about Laing’s care and raised concerns about her antibiotic management.

Any input or request for input from the clinical microbiology or infectious diseases team was not documented.

Robb said the relevance of this was the blood cultures taken on the day Laing was readmitted into hospital resulted in the identification and isolation of three bacteria, which Metcalf advised were sensitive to some medications.

Metcalf said the appropriate response would have been to alter the antimicrobials to treat all bacterial isolates in the blood culture, but there was no change in treatment.

Dr Welsh of the Waikato District Health Board acknowledged there should have been engagement by the clinical team with the clinical microbiology or infectious diseases team and noted the gap in information.

Robb said the documentation of to whom and when the results of the blood cultures were received is not clear within records and steps taken to consult with other teams was also not documented.

In a response to the coroner, Waikato DHB said it would review its policies and ensure it was continually improving in this area.