“Systemic” issues at Whangārei Hospital led to a woman's death after she was given a penicillin-based antibiotic despite being allergic to penicillin.
The woman aged in her 80s underwent elective pelvic floor repair surgery at the hospital in 2020.
She’d known about her penicillin allergy for some time, having had her first reaction in the 2000s. Since then, she wore an anaphylactic shock warning necklace and always asked pharmacists about drugs she was prescribed.
Following the successful surgery, the woman was discharged and seemed to be on the mend, with her family surprised at how well she was doing.
However, she was re-admitted weeks later - feeling cold and shivering - with an infection from the surgery believed to be the cause.
When she was first triaged, workers knew about her allergy and administered Cefuroxime, an antibiotic. This was given to her slowly because of the allergy.
The woman was later transferred to a surgical ward by the gynaecology team with urosepsis (an infection of her urine and kidneys) that was unrelated to her surgery. According to the report made by the Health and Disability Commissioner (HDC), she was still wearing her anaphylactic shock necklace.
It was here when the house officer treating the woman made a fatal mistake.
A doctor, seeing that Augmentin (a penicillin-based antibiotic) was more effective than Cefuroxime, made the decision to change her IV drip. He failed to see notes of her allergy on documents, and the woman was not informed of the change.
The doctor told the HDC he “did not consider a penicillin allergy, but was reassured because Mrs A was already receiving IV cefuroxime”.
“Traditional teaching is that if someone has an allergy to penicillin, Cefuroxime would not be prescribed.”
He also noted the ward was understaffed, with workers being assigned to other departments.
A nurse was the one who administered the antibiotic and said the woman had told her she wasn’t aware of any allergies.
In hindsight, the nurse said: “She cannot be certain that [the woman] understood the question regarding her allergy status, or whether it did not occur to her to mention the penicillin allergy.”
After the antibiotic was administered, the woman started turning blue, and the nurse suspected she was suffering anaphylactic shock.
Attempts to resuscitate the woman were unsuccessful, and she died two hours later.
The woman’s death was investigated by the HDC, who found that “systemic factors” contributed to what happened.
Health and Disability Commissioner Morag McDowell found both the hospital and three staff members had breached the Code of Health & Disability Services Consumer’s Rights.
In a statement McDowell was “critical of a lack of flexibility to enable adequate staffing during a busy weekend with a number of high acuity patients, and of the handover process which did not consistently support the sharing of important information such as medication allergies”.
McDowell said the woman’s death had a “devastating impact” on her family, and the errors in her treatment “clearly affected” the staff involved.
“Te Whatu Ora Te Tai Tokerau accepted that systemic factors contributed to the error and agreed electronic prescribing is key to preventing medication errors and that it had been requesting for this to be prioritised for many years,” a statement reads.
The commissioner made a number of suggestions to Te Whatu Ora on how they can prevent similar deaths.
She asked it to consider improving how it documents drug allergies and “implement improvements that mitigate the risk of inadvertent administration of a drug to which the patient is allergic.”
SHARE ME