Misdiagnosis highlights need for more ED staff

Isdale Williams. Photo by Craig Baxter.
Isdale Williams. Photo by Craig Baxter.
A woman whose broken back was misdiagnosed at Dunedin Hospital's emergency department as abrasions and bruises says the department must get the extra specialists that doctors say it needs.

Dunedin resident Isdale Williams, who was injured in a boat on Otago Harbour, endured months of pain and uncertainty "shuffling" around, feeling confused and upset about why she had not recovered.

She had spinal fusion surgery for a burst fracture in May 2009 - 16 months after the accident - which her surgeon told her should probably have taken place in the immediate aftermath of the injury.

The emergency specialist who missed Mrs Williams' fracture advised the Health and Disability Commissioner last August that extra specialists being hired for the department's new short stay unit would improve treatment for patients such as Mrs Williams.

Earlier this month, the senior doctors' union, the Association of Salaried Medical Specialists, said the DHB had backtracked on plans to hire 4.5 senior medical officers.

Mrs Williams said the doctors' appeal for the recruitment of the extra ED specialists had to be heeded.

She said the clinicians who treated her were rushed off their feet and did not listen properly; this lack of attentiveness being the catalyst for the misdiagnosis.

After making a lengthy investigation of her case, Health and Disability Commissioner Anthony Hill took no formal action, but in his decision last year criticised aspects of her care.

Mrs Williams was injured when she was flung from a sitting position on to the side of a boat that had rapidly accelerated. She was given morphine by St John on the way to Dunedin Hospital, during which time she also vomited.

The hospital sought to discharge her after her X-rays, but her husband insisted on her staying the night, Mrs Williams said.

She had "immense respect" for Dunedin Hospital, and did not wish to be negative, but said something had gone wrong in the management of some patients.

She did not know whether her eventual outcome would have been better had she been correctly diagnosed, but was grateful to be walking.

The independent report Mr Hill commissioned found Mrs Williams' care represented a mild to moderate departure from the standard.

Mr Hill said Mrs Williams' treatment was not adequately documented and she was not properly reviewed before discharge.

Her injury was not properly explained, nor was she advised about follow-ups. Her X-rays were not reviewed until 12 days after they were taken, an "unacceptable delay" .

Of missing the spinal fracture, Mr Hill said an emergency specialist doctor was not expected to have the same expertise as an orthopaedic surgeon.

The fracture on her X-ray was misread as an old injury.

A letter to Mr Hill from the emergency specialist who treated Mrs Williams said extra senior doctors were due to be appointed.

In the letter, the specialist said it was not possible for a sole senior doctor to properly document and review patients, as well as run ED and deal with acute patients.

"With this extra senior doctor [for every shift] on duty, there should be adequate time available to fully explain and document the diagnosis and treatment plan for each patient that is reviewed ...

"In this way, patients like Mrs Williams will have their diagnosis fully explained to them, as well as details about follow up and warning signs," the specialist said in the letter.

In response, Otago chief medical officer Richard Bunton said last week that having two senior doctors on every shift was the "gold standard", but not always the best use of resources.

He said the union had got it wrong about the 4.5 specialists.

The DHB had used a resource allocation term, which did not mean the unit would be staffed with extra specialists.

However, the ED was getting additional staff in the form of nurses, registrars, and specialists. The exact composition of the extra staffing was a work in progress, but appointments were being made.


Emergency department - the good, the bad
Southern District Health Board.

• For first quarter 2011-12, SDHB 17th of 20 DHBs for ED waiting times.
• 85% of patients treated and discharged or referred to another ward within six hours.
• Result better than previous quarters.
• Southland Hospital ED's performance improves overall DHB figure.
• Six DHBs meet 95% target.
• Internal improvement project "6 Hours - It Matters!" under way.
• Internal report last year puts ED's troubles in the context of wider dysfunction at Dunedin Hospital.
• A 10-bed short stay ED unit to open this year aims to improve patient monitoring and flow.

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