Source: Radio New Zealand
Deputy Health and Disability Commissioner Carolyn Cooper. Supplied
The health watchdog has criticised inadequate staffing at Ōamaru Hospital’s emergency department after investigating the death of an elderly woman.
The 93-year-old was given the wrong amount of saline as a result of a prescribing error in November 2023.
Deputy Health and Disability Commissioner Carolyn Cooper said while she was concerned about the care provided to the woman after multiple errors by different staff, a postmortem found the prescribing error did not cause her death.
“While I acknowledge that individual staff were involved, I consider that the workload at the time meant that staff could not carry out their respective roles adequately,” she said.
Cooper found Waitaki District Health Services, which managed the hospital at the time, bore the responsibility of ensuring safe staffing and had breached the woman’s right to health care that minimised the potential harm and optimised her quality of life.
“I am critical that the ED (emergency department) did not have adequate staffing levels to manage high patient numbers and that this had an impact on the standard of care provided to Mrs A by multiple staff,” she said.
Cooper recommended Waitaki District Health Services apologise to the woman’s family and noted the organisation had continued to recruit and employ more staff and boosted training for nursing staff on the infusion of IV fluids.
She said Waitaki had guidelines in place relating to saline but steps had been taken to make the information more widely available.
A sole doctor on a busy emergency department night shift
The woman was seen by a hospital doctor who diagnosed her with pneumonia, urinary retention and severe hyponatraemia, or abnormally low sodium levels in her blood, in November 2023.
He prescribed her 100ml of three per cent saline at a rate of 200ml per hour before his shift finished and a different doctor took over her care.
Waitaki District Health Services acknowledged to the commissioner that the emergency department was busy.
“Dr C was the sole doctor covering Ōamaru Hospital on night shift and was responsible for all ED patients, the acute medical/ward patients, arranging transfers, speaking to consultants at Dunedin Hospital, and taking phone calls from nursing homes, as Ōamaru Hospital provides all urgent care to the region after hours,” the report said.
A registered nurse found a 1000ml bag and showed it to a nursing student, who told him the chart was wrong and it should read 1000ml not 100ml.
The night shift doctor prescribed a 1000ml bag to run over 10 hours because he believed it was a more cautious approach and asked for her levels to be checked in a few hours.
The doctor acknowledged he was not overly familiar with prescribing the saline solution and told the commissioner that there were no hospital guidelines and staff had not raised any concerns about his decision.
Staff noted there was an audible crackle while she was breathing but her condition did not appear to have deteriorated and she was alert.
It was not until the night shift doctor checked her sodium levels just before the morning handover that he realised the rise was too rapid, telling nurses to stop her fluids immediately.
When her original doctor arrived at work, he realised the error and started reversing the sodium correction but the woman soon became unresponsive and died.
A postmortem found she died from pneumonia and sepsis and the sodium correction had not been too rapid.
Cooper raised concerns about the night shift doctor’s actions because he prescribed the larger saline bag despite being unfamiliar with the solution and did not look up the hospital’s guidelines.
“Severe hyponatraemia in a severely ill elderly respiratory patient is such a red flag, and ultimately Mrs A’s care was the responsibility of Dr C despite his suggestion that staff did not raise concerns on reading his prescription,” she said.
Cooper said the woman’s treatment was a moderate departure for the accepted standard of care because the prescribing error was not responsible for her death and the workload was “at the limit of what can be considered safe”.
She also criticised the shift leader and nursing student who administered the dose despite concerns the prescription was incorrect, saying the shift leader did not adequately supervise the student.
Cooper found the woman’s deteriorating condition might have been noticed earlier if her vitals had been better assessed and documented.
She recommended Health New Zealand Southern, which took over operations at Ōamaru Hospital in July 2024, provide training for emergency department staff and rural hospitals on managing abnormally low sodium levels, update the commissioner on staffing levels, confirm different saline bags were kept in separate places and show it was improving its documentation.
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– Published by EveningReport.nz and AsiaPacificReport.nz, see: MIL OSI in partnership with Radio New Zealand
