Source: Radio New Zealand
Christchurch hospital. RNZ / Nate McKinnon
A woman who arrived at Christchurch Hospital’s emergency department in acute pain died the next day after staff missed signs she had sepsis.
The 65-year-old patient died of urosepsis, a life-threatening complication of a urinary tract infection, in January 2022.
In a report released on Tuesday, deputy Health and Disability Commissioner Carolyn Cooper said the hospital failed to provide reasonable care, making “severe departures from standard practice”.
“I concur that there was a failure to recognise urosepsis in a timely way, which subsequently led to a lack of appropriate treatment being provided to [the woman],” she said.
Health NZ completed an adverse event review (AER) into the woman’s care and also found delays in the recognition and treatment of urosepsis.
The report said the woman had a history of high blood pressure and Crohn’s disease, with a previous bowel resection, small bowel obstructions and a kidney stone.
The woman was diagnosed with renal colic after being assessed in the ED and given pain relief.
She was then transferred to the hospital’s urology unit.
The report said the woman was experiencing prolonged hypertension by the next morning.
“Throughout the day, [the woman] received intravenous fluid boluses as the primary intervention for her hypotension. However, her [high blood pressure] did not respond to this adequately,” the report said.
“The AER found that a lack of response or improvement from the fluid should have triggered a challenge of the diagnosis and consideration of other possible differential diagnoses or causes. However, this did not occur.”
Medical reviews at the time suggested the woman’s hypotension may have been due to the effects of the pain relief.
Clinicians noted the woman was “chirpy and chatty” throughout the day and that she did not have a fever but clinical notes also recorded instances of the woman shivering, a symptom of sepsis, the report said.
“The AER found that clinical staff exhibited anchoring bias – that is, there was an over-reliance on the absence of a fever, which normally is present in urosepsis, despite the lack of improvement over the day,” the report said.
“While the nurse in charge, the house officer, and the registrar were informed of [the woman’s] deterioration, there is no evidence of a senior medical officer consultation (after the initial ward round at 8am), consideration of involvement of the Intensive Care Unit (ICU) team, or a rapid response call being made when [the woman’s] observations were in the red and blue zone, as required by the mandatory escalation pathway.”
The deputy commissioner found an “early warning score” chart had several incomplete observations throughout the day, with the total score also not recorded, which was not in line with Health NZ policy.
Cooper criticised Health NZ’s failure to follow its mandatory escalation and urosepsis policies and the renal colic protocol.
“Had these policies been adhered to, the delay in the diagnosis of urosepsis may have been avoided,” she said.
Cooper recommended Health NZ Waitaha Canterbury apologise to the woman’s family.
She also recommended developing an education and training plan for staff around diagnosing urosepsis and the importance of medical documentation.
Health NZ told the commissioner it had changed its renal colic protocols to highlight the need to consider an alternative diagnosis, run an education refresher on sepsis and run an education session for urology nurses.
Health NZ has been contacted for comment.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
