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Stroke victim update: U-turn on investigation

Jenny Rose before her stroke. PHOTO/SUPPLIED

Family to be updated regularly

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Last Friday the Times-Age detailed the story of Jenny Rose, the 70-year-old Carterton woman who suffered a stroke in 2018. The Health and Disability Commissioner has now agreed to continue investigating the family’s complaint, despite initially returning a decision in January to take no further action.

Stuart McKay, Rose’s son-in-law, had been organising the information-gathering process and lodged the complaint on behalf of the other members of the Rose family, which includes husband Donald; son Hayden; and daughter Megan.

McKay said the media coverage likely prompted HDC to continue looking into the complaint, and that they had now approached Carterton Medical Centre for Rose’s clinical records.

“It’s important that institutions such as the Health and Disability Commissioner are recognised when they do make the right call,” McKay said.

“I would also like to emphasise that the family wish no ill will to the nurse practitioner [who reportedly lowered Rose’s warfarin dosage from 4mg to 3mg daily].”

McKay said they were questioning whether adequate training and checks were actioned before the medical centres were tasked with taking on warfarin dosing.

Rose’s stroke occurred at a time when responsibility for blood monitoring and warfarin dosages had been shifted from Wellington SCL [a world-class medical laboratory] to primary health care providers in Wairarapa [Rose’s was the medical centre].

“I am quite concerned that this may have not occurred, and the nurse practitioner was simply dumped with this new responsibility,” McKay said.

In a communication to the family, HDC complaints assessor Caitlin Auger said that, based on the report from the Accident Compensation Corporation and the other information provided, “it has now been decided that we will continue with our assessment of your complaint by requesting [Rose’s] clinical records from Carterton Medical Centre”.

Auger said a timeline would be difficult to provide, but that the entity would aim to update the family every six to eight weeks with the progress of the investigation.

A chain of errors

  • Warfarin is a blood-thinning medication given to patients who are at risk of strokes.
  • An international normalised ratio test shows the blood’s ability to clot, it’s taken regularly via a pinprick on the finger.
  • Dosage support and patient INR data were being switched from a large laboratory in Wellington, to regional medical centres. There were concerns about how this would be managed smoothly.
  • At Carterton Medical Centre, Rose’s warfarin dosage was lowered by 25 per cent after a higher-than-normal INR reading.
  • This lower level was maintained by CMC, who had reportedly not been given Rose’s comprehensive dosage and INR history.
  • According to the ACC’s report, it was in this window that the clot formed that led to the stroke.

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