Auckland City Hospital. Photo: 123rf.com
The health watchdog has criticised Auckland City Hospital's standards after a patient got irreversible brain damage after an overdose of morphine.
In 2019, the man's family lodged a complaint with the Health and Disability Commissioner (HDC) and the findings, released Monday, said the hospital breached the Code of Health and Disability Services Consumers' Rights over the care of an oncology patient.
HDC says the case will be reviewed and, if justified, referred to the Human Rights Review Tribunal for penalties.
'He will never be able to get back to work'
In 2019, the patient was receiving treatment for throat cancer and was admitted to Auckland City Hospital with severe inflammation and ulceration of his digestive tract.
In order to ease the patient's pain, the doctor prescribed morphine injections, through a pump that automatically administers the medication.
The morphine infusion needed to be done with constant monitoring of vital signs, including four-hourly checks of the injections to avoid overdosing.
The findings said on the night of the incident the hospital was understaffed, and a resource nurse was called in to look after the ward.
The nurse said she checked the patient when she started her shift, but did not conclude a full vital check as the patient was "sleeping soundly".
In between other patients and new hospital arrivals, the findings said the nurse checked on the man twice more during the night.
The next morning, the patient had low blood oxygen levels and a code red was called by another nurse, moving the man to the ICU due to opioid narcosis.
The man was treated and sent home, but his wife started to notice that simple tasks, like changing the TV channels, were difficult for her husband.
The morphine overdose was later found to have caused the patient irreversible brain damage, with resting tremors, increased muscle rigidity and limb weakness.
The patient's wife told HDC his condition has deteriorated since the diagnosis.
"[He] has been left with a brain injury and a broken femur which can't be operated on due to the brain injury. He will never be able to go back to work and he is really relying on me, which makes it hard for me to do my job.
"I really feel like Auckland Hospital just dropped us and wasn't really wanting to help us."
In 2020, Auckland Hospital apologised to the family and said it was "committed to making improvements to minimise the risk of an adverse incident such as occurred in the man's case happening again in the future."
Hospital policies not clear - HDC
In her findings, deputy health and disability commissioner Vanessa Caldwell said the nurse did not complete all the needed vital checks during the night, contributing to the man's morphine overdose.
Caldwell said the nurse also failed on calling a code red alarm when the patient was discovered to have low blood oxygen levels.
"I am critical of the nurse's lack of monitoring and documentation, and for leaving the man on his own while [the nurse] sought assistance, instead of undertaking an immediate assessment and raising the alarm."
To the HDC, the nurse said the patient wasn't showing any signs of distress and she became busy dealing with other patients who required immediate attention.
"I understand that these assessments [level of consciousness, airway, breathing and circulation] would be appropriate for an unresponsive patient, but [the patient] wasn't showing any signs of distress and he was responsive (though sleepy/drowsy)," the nurse said.
"I understand in reflection what I should have done differently."
Caldwell was also critical that the hospital's policies were not sufficiently clear to support safe practices around opiates.
"This is evident in the practices followed by staff that were not in line with the expected standard of care.
"Opiates are known to suppress breathing and to affect renal function. The risk for this patient was not monitored adequately."
In the HDC findings, health experts said there were systemic issues at Auckland District Health Board (ADHB) due to a lack of clear policies and guidelines, as well as a stretched workforce, with a ratio of one nurse per nine patients.
ADHB said since the incident, it has increased the number of nurses on the oncology ward nightshift from three to four, and was using a tool to identify staffing deficits.
It has also created new guidelines on the use of opioids, including identification and monitoring of overdosages.
In her findings Caldwell made several recommendations for ADHB, including education for nursing staff, a reference guide for management of opioid overdose, and giving the patient affected and his family a formal apology.
The nurse involved was also asked to give a written apology to the man and undertake further training on emergency procedures, local policies on observations, and documentation.
Auckland City Hospital was referred by the commissioner to the director of proceedings, which will review the circumstances to determine whether further action is appropriate.
If determined that proceedings are justified, the case goes to the Human Rights Review Tribunal.