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A decision from the Health and Disability Commissioner said SDHB staff missed opportunities to exercise sound clinical judgement and properly assess how critical the patient's condition was.
The decision says a woman in her sixties presented to the emergency department in 2019 for a possible pulmonary embolism, which was quickly confirmed by a CT scan.
Despite the embolism being described as massive, with significant effect on the cardiovascular system, the staff adopted a "wait and see" approach while they considered treating her with thrombolysis - a treatment used to dissolve blood clots.
Although the woman was critically unwell, junior staff did not escalate her care to a senior medical officer, and she was not treated with anything other than fluids.
The woman died 17 hours after she was admitted to hospital.
Commissioner Morag McDowell said SDHB staff failed to exercise sound clinical judgement and assess the woman’s condition critically.
In addition, they failed to escalate the woman’s care to the responsible senior medical officer and initiate treatment (thrombolysis) when it was clinically indicated, and to communicate with each other effectively.
Ms McDowell said these failures indicated a pattern of poor care across the woman’s patient journey, as well as a culture of non-compliance with SDHB’s policies and procedures.
"There were repeat failures involving numerous individuals across the ED and the respiratory team, and I consider this to be a service delivery failure for which, ultimately, SDHB is responsible," Ms McDowell said.
The commissioner made a number of recommendations to SDHB, including that the DHB:
- Consider whether its guidelines for thrombolysis in patients with acute pulmonary embolism could be strengthened further to include specific reference to indicators of shock;
- Use the report as an anonymised case study;
- Review the medical staffing levels at the public hospital overnight to ensure that there is an adequate mix of skills and capacity to meet acuity of demand;
- Consider the Australasian College of Emergency Medicine’s Statement on "Responsibility of Care in Emergency Departments" and use this to created its own guideline with regard to patients in ED awaiting inpatient beds;
- Consider developing a policy and process to allow for increased supervision of resident medical officers during their first few weeks of a rotation; and
- Promote awareness or develop a process or pathway for nurses to contact senior doctors directly in appropriate circumstances.
- In addition, the Commissioner referred SDHB to the Director of Proceedings.