Newstalk ZB
A family has described watching their loved one deteriorate over three days while in hospital, before dying during a transfer, as severely traumatic. The woman was left with no pain relief for six hours as sepsis took hold, while family members spent an agonising night watching her rapidly decline with no explanation, or doctors in sight. Now, the Health and Disability Commission (HDC) has found there were several systemic and organisational issues at Wairarapa Hospital which breached the 54-year-old’s rights to reasonable care. According to today’s HDC report, in August 2020, the woman went to her local GP with rectal bleeding and, after examinations, was diagnosed with haemorrhoids and given topical cream. Six months later, she reported a flare-up of symptoms and was given another prescription of topical cream. A referral was made for a private colonoscopy, which occurred a month later, and a tumour was found. Another scan a month later confirmed the colorectal cancer had spread. In July 2021, a plan was made for her to undergo chemotherapy - however, she required a temporary colostomy bag, or stoma, before the treatment. The surgery was completed and she began chemo on August 5. Within days, the woman developed severe abdominal pain and collapsed at home. A nurse who conducted a house visit told the HDC the woman stabilised; however, this was not noted in her medical file. Around this time, her cancer care co-ordinator went on leave, and nobody was assigned to fill her role. What followed was three traumatic days at Wairarapa Hospital as her family watched her slowly deteriorate, and eventually die. She arrived at the emergency department with abdominal pain, vomiting, and also collapsed. After tests, the staff suspected chemotherapy‑related sepsis. She was admitted to the Medical Surgical Ward (MSW) for fluids, antibiotics, and monitoring. However, her condition worsened overnight. The woman vomited repeatedly, required escalating pain relief, and remained unsettled. By morning, she was pale, sweaty and blood tests showed clear signs of infection. A CT scan revealed a large bowel obstruction. Crucially, it did not show a perforation – a detail that would later become central to the investigation. “The fact that no bowel perforation was seen at this time is important, as following her death it was identified that Mrs A’s bowel had perforated approximately 21cm from the end of the stoma,” HDC Commissioner Morag McDowell said in her report. “How and when the perforation occurred is relevant information to assist in determining whether an appropriate standard of care was met.” Family members said they were traumatised as they watched their mother taken to the high dependency unit. Photo / 123rf A surgeon drained 1.1 litres of fluid from the colon, which gave her a short-lived reprieve. Twice, her blood pressure dropped, with her vital signs being in the red zone, meaning urgent escalation of care was required. Health NZ policy states that every time vital signs are measured, the Early Warning Score (EWS) must be calculated. However, this was not done in the 15 hours after the second time her blood pressure dropped. She was given IV fluids, taken off pain relief and placed on a portable monitor for intermittent recording of her vital signs. However, the details of the last patient were still logged into the monitor. At some point, a high dependency unit (HDU) staff member noticed the deteriorating vital signs. However, staff could not locate the patient because of the incorrect details. Despite her charts showing she was in the critical “blue zone”, it was not for another two hours and 20 minutes that an emergency bell was activated by a nurse, in front of family members. “It is unclear why the [Medical Emergency Team] call was not made earlier than it occurred,” the report said. With the woman still conscious, she was transferred to the HDU but no one advised the woman or her family what was happening, causing them t...
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