An overstretched and under-resourced Palmerston North emergency department was found to have contributed to the death of a woman who fractured her nose from a fall, before dying from oxygen deprivation in hospital.
The woman, who was in her 70s, was agitated when she was taken to Palmerston North Hospital's emergency department after fracturing her nose in a fall at home in 2018.
The woman - who had a history of mental health combined with cardiorespiratory issues - was given a range of sedatives to manage her agitation. However, she went into cardiorespiratory arrest and had to be resuscitated.
She was transferred to the intensive care unit after receiving surgery to control her bleeding nose, but was found to have sustained a hypoxic brain injury.
The woman died after she was taken off life support four days later.
Deputy Health and Disability Commissioner Carolyn Cooper found Te Whatu Ora - Te Pae Hauora o Ruahine o Tararua MidCentral, formerly known as the MidCentral District Health Board, in breach of the Code of Health and Disability Consumers’ Rights after failing to provide services with reasonable care and skill, and the right to cooperation among providers.
A registrar was also found in breach of Right 4(1) of the Code for prescribing medications to the woman without input from senior medical staff.
Cooper said in her decision, released today, that the ED lacked a system to guide staff in their actions when the woman presented to the ED.
She also found significant deficiencies in the care provided to the woman, including inadequate monitoring and poor communication between the different disciplines involved in the woman’s care.
Cooper said the findings highlight the importance of ensuring sedation is performed in a monitored area by appropriately skilled staff who are able to intervene when they recognise complications.
"Public hospitals have a duty to provide services of an appropriate standard… Ms A presented to ED with an acute and moderately severe nosebleed following an unwitnessed fall,” she said.
Her age and history of mental health and cardio respiratory disease meant she was a particularly vulnerable patient who required close monitoring. Unfortunately, despite knowing these factors, the care provided to her was deficient in several respects."
Te Whatu Ora - Te Pae Hauora o Ruahine o Tararua MidCentral has since implemented several changes, including updating its policies for procedural sedation and developing guidelines for sedation of agitated patients.
Cooper recommended it provide a written apology to the woman’s family.
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