Health and Disability Commissioner Anthony Hill has found that the Northland District Health Board failed to treat a 73-year-old patient who died in 2014 of infective endocarditis with reasonable skill and care.

In his report, Hill acknowledged that the hospital’s emergency department (ED) was exceptionally busy the day that ‘Mr B’ presented for the second time in just over a week. He also acknowledged the Ministry of Health target was for patients to be transferred from ED within six hours, but he said that it was unacceptable for Mr B to have been transferred to a surgical ward “in order to meet a target” when it was clinically inappropriate.

His report found that ED ‘busyness’ had resulted in delays in triage, important aspects of Mr B’s management plan (including insertion of a catheter and commencement of a fluid balance chart) not being started while he was in ED, and also extended delays in a requested medical review.

Receipt of the elevated blood test results for the heart attack marker Troponin T, which had been ordered by the ED nurse, was also delayed as there was no clear process for escalating nurse-ordered tests to the patient’s doctor, surgical registrar ‘Dr A’. The combination of busyness, the six-hour ED target, delayed medical review and late receipt of the Troponin T results meant Mr B’s planned transfer to a surgical ward was carried out by ED nursing staff when, in retrospect, his signs of sepsis and a heart attack meant he should have been considered for higher level care (though no beds were available in either the ICU or coronary care unit at the time of his admission).

The HDC heard that that it was not unusual for the surgical team to fail to complete ED-to-ward bed request transfer forms, which were left for the ED nursing staff to do instead. Hill said he was critical that the DHB’s ward transfer practice did not match its policy, which would have required that Dr A, rather than nursing staff, complete the bed request form (see case summary below for more details).

Among a number of recommendations made by the commissioner was for the DHB to audit the new triage process it had since introduced; for the DHB to develop a clear policy for who is responsible for following up test results ordered by ED registered nurses; and for it to remind all ED staff that a patient transfer and location must be “clinically appropriate”.

Other recommendations included that the DHB review its sepsis management policy and adult sepsis pathway (and provide training for relevant staff on the new pathway); consider implementing a system that requires the laboratory to alert the patient’s treating clinician urgently; review the ED’s standard operating procedure; develop a care escalation plan for the general medicine team; and review the role of on-call consultants to ensure that adequate supervision of junior doctors is occurring. In addition, he requested that the DHB send a written apology to Mr B’s family.

The DHB told HDC that since the 2014 event “significant changes” to its ED triage process had been made, including building a new triage area that allows a patient to be seen by a triage nurse in a private area. In addition, the number of medical registrars available to see acute patients in the ED had been increased from one to two during the busier parts of the day and it now had an Adult Sepsis Pathway for ED. A new ED treatment chart with space allocated specifically for detailing by nursing staff of the blood tests they had ordered had also been developed.


‘Mr B’ was first admitted to the hospital’s surgical ward a week before his death with a four-week history of diarrhoea and abdominal pain.

Mr B was discharged as surgical staff thought his symptoms, which included variable temperatures and a borderline elevated white cell count, were due to his gout medication, but a plan was put in place for an urgent outpatient colonoscopy.

On Day 8 Mr B’s GP phoned the surgical registrar Dr A as Mr B was still unwell, and Dr A accepted him for review in the ED.

Mr B walked into ED just before 10am and was triaged by an RN 35 minutes later on a particularly busy day with a ‘Code Orange’ being called at 10.30am. He was given a triage score of three. At 10.50am Mr B was given an initial review by Dr A, who gave a provisional diagnosis of abdominal sepsis. He requested a medical review by medical registrar Dr D, but Dr D was very busy with the influx of patients.

Nurse E started IV fluids and at 11.20am requested several routine blood tests, including a Troponin T test, because of the patient’s heart history, but this was not recorded on the patient’s ED clinical record. She told HDC that regrettably an ECG was not completed but she was not focused on a complete cardiac work-up, given Mr B’s repeat referral to the surgical team and his presenting symptoms suggesting a gastric condition. The DHB said it was usual practice for ED nurses to initiate blood tests and nurses were not responsible for viewing or acting on the results but were expected to indicate which tests were ordered on the ED clinical record.

At 11.40am Nurse E recorded that the plan was to admit Mr B to the surgical ward. The abnormal Troponin T results were reported by the lab at 12.13pm, but there was no automatic process for alerting Dr A and he told HDC that as he was unaware they had been ordered he did not look out for the results or chase them up.

Dr A reviewed Mr B for a second time when he was halfway through his first bag of IV fluid and noted he was responding to the treatment but was still sleepy. At 1.20pm RN E recorded that Mr B was transferred to a room closer to the desk because of his low blood pressure. At 1.53pm she completed an ED to Ward bed request form for the surgical ward, based on his GP referral to the surgical team, his gastric symptoms and his recent admission to the surgical ward.

At 2.35pm Dr A viewed Mr B’s blood test results, including the Troponin T result, which indicated sepsis and heart damage. He spoke to medical registrar Dr D again, who said he would review Mr B soon but was still busy.

Mr B was transferred to the surgical ward shortly before 3pm without blood cultures having been taken, a catheter inserted, a catheter specimen of urine taken, a fluid balance chart commenced, stool cultures taken, or an ECG undertaken.

RN E told HDC that starting a fluid balance chart would have been ideal practice, but it was exceptionally busy that day and it was not unusual for care plans not to be fully completed in ED. “In the turmoil of a stressed ward, completing tasks, procedures and paperwork becomes a juggle whilst prioritising patient care,” she said.

By the time Dr D went to review Mr B, he had been transferred to the surgical ward, so he went there and carried out a review (about four and a half hours after medical review was first requested) and put in a management plan.

Dr A prescribed Mr B antibiotics at approximately 3pm. Between 3pm and 4.25pm, Mr B underwent an ECG, chest X-ray, and medical review. Sadly, Mr B’s condition deteriorated and he died at 5.17pm.

A subsequent post-mortem examination showed infective endocarditis of the aortic valve involving adjacent heart tissue, fibrinous pericarditis and evidence of heart failure. Death was considered to be due to infective endocarditis.

The full report can be viewed here.


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