A southern skiing holiday went horribly wrong for a tourist who not only broke a leg but also contracted sepsis while in the care of Dunedin Hospital.
Despite the tourist’s serious illness, hospital staff went ahead with plans to repatriate the woman, only for air ambulance crew to refuse to fly her because they felt she was too unwell to travel.
Deputy health and disability commissioner Deborah James investigated the way the woman was cared for and yesterday issued a report which criticised hospital procedures for detecting and monitoring sepsis, the decision to transfer the woman despite her being desperately unwell, and the note taking of some of the nurses who looked after her.
Because of the number of clinical staff involved in the care of the woman, the commissioner chose to make an adverse finding against the former Southern District Health Board for its patient management processes rather than censure any individual staff member.
"The day prior to the woman’s scheduled repatriation, her condition clearly and progressively deteriorated," Ms James said.
"Had abnormal blood test results been reviewed and acted on earlier, the diagnosis of sepsis may have been arrived at earlier, which would have led to earlier treatment ... Given that the woman’s condition was continuing to deteriorate, I would have expected the clinical staff to have postponed the repatriation earlier than they did."
The woman broke her leg on July 23, 2019 while skiing, and Dunedin Hospital surgeons operated on her leg that day.
Ms James said the surgical care was excellent, but the case raised serious concerns about the quality of the woman’s post-operative care.
"Blood tests and blood cultures were ordered, but no action was taken on the abnormal results," she said.
"It took over 10 hours from when the blood tests were requested for treatment to be provided to the woman."
The woman was due to be repatriated to her home country and a transfer had been arranged for the middle of the night.
Air ambulance crew deemed the woman too ill to fly and Ms James said it was unreasonable of hospital staff to have decided her travel should go ahead as planned.
"In my view, the repatriation should have been cancelled at 10pm, when it was clear that the woman’s condition was unstable and not improving," she said.
"At the very least, it should have been cancelled at 1am ... Instead, staff proceeded with plans to repatriate the woman, and it was the Air Ambulance’s medical director who finally recognised that the woman was too unwell and declined the transfer."
Ms James also questioned the note taking of some of the nurses who cared for the patient.
She said having English as a second language might have explained why the nurses used terms like "acting weird" and "annoying behaviour" in their clinical notes, but cautioned that as well as conveying clear meaning that nurses also needed to be professional and avoid distressing patients who might read their notes at a later date.
Ms James ordered the SDHB to apologise to the woman, develop and implement guidelines for the identification of sepsis, audit its sepsis management processes, and offer further training to the nurses involved on case documentation.
The SDHB (now Te Whatu Ora Health New Zealand Southern) said it had taken the case as an example of poor care and used it in staff training sessions, and also reviewed its processes.
Chief medical officer Dr David Gow said it accepted the HDC decision and sincerely apologised to the woman.
"We pride ourselves on delivering a high standard of care and we are very sorry that our systems and processes failed this patient," he said.
"We are working through the commissioner’s recommendations, all of which we accept, and will implement as part of our ongoing commitment to improving the quality of our care."
Dr Gow said that since the 2019 incident changes to practices had been made.
"We would like to reassure the patient, their family, and our community that these changes will reduce the chances of our systems and processes failing again."