DHB guilty of systemic failure
Cardiologist lacked information
The Wairarapa District Health Board has been found to be in breach of the Code of Health and Disability Services Consumers’ Rights for failures relating to the care of a woman with cardiac issues.
The failures by the DHB contributed to the woman being given a medication, flecainide, which caused her to go into cardiac arrest.
A report looking into the case was made public this week by Health and Disability Commissioner Anthony Hill.
In September 29, 2015 a 42-year-old woman was referred to Wairarapa DHB Emergency Department by her regular GP who requested an urgent assessment due to shortness of breath and atrial fibrillation.
An ED consultant, named “Dr B” by the report, performed an echocardiographic examination, which he interpreted as showing impaired cardiac function and she was admitted to the high dependency ward.
However, documentation of her cardiac history was described by the report as “inadequate”.
The following morning, the woman was discharged home with a prescription for anticoagulant medication. No future hospital appointments were made for an echocardiograph or cardiology follow-up.
Just after 6pm the same day the woman remained unwell and was readmitted to Wairarapa Hospital ED.
She was reviewed by an emergency consultant, who felt that nothing had changed from earlier that day and discharged her home with a plan to adhere to the earlier discharge plan.
At close to midnight on November 10, 2015 the woman was collected from her home by ambulance and admitted to ED.
She had fallen to the floor short of breath.
“Nursing staff found she had an elevated pulse rate of 160 beats per minute.”
A junior doctor, known as “Dr C” was working at the ED and looked at Dr B’s discharge summary from September.
However Dr C did not notice Dr B’s comments around the echocardiogram examination.
In the commissioner’s report Dr C said that “in any event, even if I had, the language used was vague and nondescript [‘poor squeeze’] and I am not sure that I would have understood its full relevance at the time.”
Dr C spoke to the on-call consultant physician and cardiologist three times who initially recommended adenosine, before recommending flecainide when the woman had gone into atrial fibrillation.
In the report the on-call physician and cardiologist said they wouldn’t have suggested IV flecainide had they been aware of Dr B’s assessment.
The woman was given flecainide which caused her to suffer a flecainide-induced cardiac arrest.
After a successful resuscitation, the woman was taken to another DHB [not named in the report] where she was transferred to the cardiology ward.
On November 17, while at the other DHB the anticoagulant medication the woman had been prescribed at Wairarapa DHB was stopped to enable an angiogram to be performed.
Three days later, the woman was discharged home by a house officer.
The woman’s anticoagulant medication had not been restarted, nor was there a documented plan for when it should be recommenced.
Wairarapa DHB was found to have breached the Code of Health and Disability Services Consumers’ Rights for several reasons.
There was no record of a full cardiac history and examination having been undertaken while the woman was in the high dependency ward, and no follow-up echocardiogram was arranged.
Those responsible did not pick up on Dr B’s previous ED assessment of the woman’s cardiac function.
Documentation regarding a cardiac history was inadequate.
Key information in the woman’s past ED discharge summary was not received by the on-call consultant physician and cardiologist, and so was not considered by her when prescribing flecainide, which was contraindicated in the woman’s situation.
“The net result was that the overall standard of medical care delivered to [the woman] up to the point of her cardiac arrest was poor and below that expected in a New Zealand public hospital,” the report said.
It was recommended that Wairarapa DHB report to the health commissioner with evidence that: a] the recommendations set out in its Event Investigation Report have been implemented, and any further changes that occurred after the implementation of those recommendations; and b] it has taken steps to establish a comprehensive electronic record system, with details of any effect this has had on Wairarapa DHB’s services.
Adverse comment was also made about the other DHB not restarting the woman’s anticoagulant medication when she was discharged.