Problems with the care of a woman who later died were partly blamed on under-resourcing at Palmerston North Hospital. Photo:
The deputy Health and Disability Commissioner has found an over-stretched and under-resourced Palmerston North Hospital emergency department were factors in the death of a patient in 2018.
The woman, who was aged in her 70s and had a history of mental health and heart problems, fell over at home and fractured her nose about 4am on the morning in question.
She was taken to the emergency department, where she was given sedatives to manage agitation, but she stopped breathing and lost consciousness. She had to be resuscitated.
After surgery to control her bleeding nose she was taken to intensive care, where she was found to have suffered a brain injury.
Four days later she was taken off life support and died.
In a decision released on Monday, deputy Health and Disability Commissioner Carolyn Cooper found the former MidCentral District Health Board and a doctor - a junior ear, nose and throat registrar - breached patient rights, including those to service with reasonable care and skill, and prescribing medication without input from senior staff.
She said the emergency department lacked a system to guide staff actions when the woman - who was not named in the report - arrived.
Among the "significant deficiencies" in the care provided to the woman were inadequate monitoring and poor communication between different parties involved in her care.
Cooper said the findings highlighted the importance of making sure sedation was performed in a monitored area by appropriately skilled staff able to intervene when they recognise complications.
"Public hospitals have a duty to provide services of an appropriate standard… [The woman] presented to ED with an acute and moderately severe nosebleed following an unwitnessed fall.
"Her age and history of mental health and cardio respiratory disease meant she was a particularly vulnerable patient who required close monitoring. Unfortunately, despite knowing these factors, the care provided to her was deficient in several respects."
At one stage in the emergency department the woman was given sedative midazolam in an unmonitored bed, with no one-on-one care.
The registrar who administered the drug did so without referring to a senior medical officer for guidance on its use and the amount given.
The registrar was not familiar with midazolam, which was recommended by a team from the acute mental health service that assessed the woman, and thought a member of the acute mental health team would monitor the woman. This did not happen.
Cooper's review found "ongoing challenges" with the space and design of the emergency department and a reluctance among staff to frequently call on senior colleagues for advice.
Cooper recommended Te Whatu Ora MidCentral use her report for staff training and let staff know of any changes made because of the case.
She also recommended that MidCentral and the registrar write an apology to the woman's family.