A woman suffering from a heart attack had to wait five hours for a diagnosis after health staff failed to recognise her symptoms, the Health and Disability Commissioner has found.
The woman, in her 50s, checked into a Pegasus Health facility showing symptoms of a heart attack.
Health and Disability Commissioner Morag McDowell said doctors and nurses focused for five hours on the possibility that she was suffering a negative reaction to an antibiotic, before eventually diagnosing her with a heart attack.
The woman had a clinical history that put her in the high-risk category for ischaemic heart disease but the staff still failed to recognise a heart attack, McDowell said.
McDowell found Pegasus Health in breach of the Code of Health and Disability Services Consumers’ Rights, for failing to provide services with reasonable care and skill.
She found that Pegasus Health triaged the woman incorrectly and the medical staff did not appropriately elicit her symptoms or reconsider the working diagnosis.
McDowell also concluded that conversations between nurses were not documented, the woman's symptoms were not recorded in Pegasus Health’s electronic records and nursing staff did not escalate care to medical practitioners.
"I am particularly concerned that the woman’s chest pain was known to the nursing staff, but apparently not to the two doctors who reviewed her. This raises questions, not just about the quality of the medical reviews, but the standard of communication between the nursing and medical staff.
"Given the whole context, a cardiac cause for the woman’s presentation should have been considered. This may have prompted further questioning of the woman, an earlier ECG, and possibly earlier diagnosis and treatment," McDowell said.
McDowell said responsibility lay with Pegasus Health following an investigation that identified departures from the standard of care by staff.
"Pegasus Health has a responsibility through both its staff and its processes to provide a reasonable standard of care to consumers. They should also have a system that supports good clinical decision-making, and communication and cooperation between different individual health providers.
"Throughout the woman’s presentation to Pegasus Health, multiple staff demonstrated a lack of effective written and verbal communication which was not supported by Pegasus Health’s expectations for staff to comply with the relevant standards and policies.
"Overall, the deficiencies that have been identified in the care provided to the woman highlight poor teamwork and a lack of critical thinking amongst multiple staff," McDowell said.
The HDC recommended that Pegasus Health write an apology letter to the woman, provide evidence of all triage nursing staff attendance at the College of Emergency Nurses New Zealand national triage course and use this investigation as a case study.
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