Source: Radio New Zealand
Waikato Hospital. RNZ / Simon Rogers
A diabetic patient collapsed and died in a Waikato Hospital stairwell after a delay getting urgently needed food.
The 79-year-old had a head injury and no pulse when he was found unconscious and alone by a passing nightshift doctor.
It was more than an hour after a nurse had gone to get him a sandwich to lift his blood sugar.
The Health and Disability Commission has just released a report severely critical of the care the man received in December 2019.
Waikato Hospital now makes sure the ward fridges are always stocked with snacks for diabetics.
The man, who had mild dementia and reduced mobility, was in the cardiac care unit after a heart attack.
The commission’s report said at about 9.30pm, he received a falling blood sugar reading of 4.4mmol/L and told a nurse he was worried about it.
At that level, his family had told nurses he could become unsteady on his feet.
The nurse went to get him a sandwich but there were none in the ward fridge so she had to go to another ward.
When she returned 10-15 minutes later he was not in his room so she left the sandwich by his bed.
Ten minutes later he was still not there and she wrongly assumed he was in the toilet.
A search for him did not begin for 55 minutes, the report said.
In reality, he had left his room and was last seen on CCTV footage at the snack machine.
He had walked past the nurses station and had been passed by seven staff members, none of whom appeared to check on him, the report said.
He had then gone out a fire exit and was not found until the passing doctor found him unconscious. He got help and tried to resuscitate him but could not.
By then the man’s blood sugar was just 1.8mmol/L, the report said.
Reaction from family and expert
In a written response to the commission after its initial findings, one of the man’s family members wanted to thank the health professionals who found him in “a severe hypoglycaemic crisis” and tried to save him.
“I can only imagine what it must have been like to stumble across a lost patient dying in a stairwell late at night.”
Health NZ had failed to keep the man safe, the family member said.
An expert nurse who reviewed the case, told the commission the man’s nurse should have made sure he ate the sandwich, especially because he experienced some memory loss and could have forgotten one was coming.
“Administering this very important snack is similar to administering medicine – you have to stay and watch the patient consume it,” the expert nurse said.
The initial delay in getting food was not the nurse’s fault but she should have checked if the man (Mr A) was there by knocking on the bathroom door when she returned.
“Not communicating with Mr A led to a cascade of terrible events,” the expert nurse said.
Waikato Hospital carried out its own adverse event review after the man’s death, the report said.
It found if the nurse had not had to go to another ward for a sandwich it would have allowed the man to get food more quickly and reduced the risk of him leaving the ward.
When his wife brought the man to the ED she had his medicine, his diabetic kit and his diabetic record book.
She had talked to staff many times about his needs.
But the family member told the commission the family was overlooked and not communicated with properly.
Very poor care
Deputy commissioner Carolyn Cooper gave her condolences to Mr A’s family.
“Mrs A was closely involved in her husband’s care, and his sudden death has been traumatic for her and the family,” she said.
Cooper found some of what happened was a severe departure from the expected level of care, and when it came to nursing management of his diabetes, it was “very poor”.
She was critical of the lack of food on the ward, the lack of communication with the man to make sure he had eaten, the delay in the search for him and the lack of a system to alert staff when a patient left the ward.
Health New Zealand’s response
Waikato Hospital now makes sure the fridges in all its cardiac units are checked to ensure there are enough snacks for patients with diabetes.
It has given staff more diabetes and dementia management training, with at risk patients now placed closer to the nurses station.
There is an alert system on the unlocked doors at the fire exit stairs.
In a response to questions from RNZ, Waikato Hospital’s chief medical officer Margaret Fisher said it had apologised to the family for the distress and the lasting impact from the incident.
The hospital accepted the commission’s findings that it did not meet the standard of care.
It had many of the improvements mentioned in the report and was also looking at creating a patient-tracking system in acute care areas, she said.
The hospital did not answer RNZ’s questions about how well staff the ward was on the night the man died.
Sign up for Ngā Pitopito Kōrero, a daily newsletter curated by our editors and delivered straight to your inbox every weekday.
– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
