Nelson Marlborough Health should have reacted quicker to signs a woman who had undergone bowel surgery was deteriorating, the Health and Disability Commissioner has found.
A 65-year-old woman died after complications following bowel surgery, which prompted a formal complaint against the regional health board.
In a recent decision, Health and Disability Commissioner Anthony Hill said the Nelson Marlborough Health should have reacted more quickly to signs the woman was deteriorating following surgery and provided treatment which could have saved her life.
The patient, referred to in the decision as Mrs B, was admitted to hospital in 2014 for bowel surgery following radiation treatment for bowel cancer.
The report says “although the procedure appeared to have gone well, Mrs B’s condition deteriorated” after the operation.
Four days later she was transferred to the Intensive Care Unit where she died that afternoon, following a diagnosis of acute respiratory distress.
A post-mortem found the cause of death was pneumonia due to aspiration.
A day after her surgery it was reported she was recovering well, however, that afternoon Mrs B was beginning to show signs of constipation and intolerance to oral intake.
She also had a high white cell count, which was considered to be a normal response to the operation at that time.
The next day the woman experienced vomiting and abdominal distension.
On day five her condition worsened, and she was transferred to the ICU where she died at 4.33pm.
Hill found the DHB failed to pick up the earlier signs and therefore did not provide the appropriate treatment quick enough.
He said the hospital should have investigated whether the high white cell count was a sign of infection and criticised staff for not considering the possibility of inserting a nasogastric tube on the morning that the woman was transferred to ICU with breathing problems.
“I am concerned that this did not occur,” Hill said.
Further concerns about the care she received while in ICU were also raised and found there had been a delay in escalating her care to the consultant anaesthetist.
Hill also found that invasive ventilation should have been implemented sooner when it was clear that the woman was experiencing severe respiratory failure.
In response to the findings that Nelson Marlborough District Health Board was in breach of the Code of Health and Disability Services Consumers’ Rights, the DHB has provided a written apology to the woman’s family.
It has also produced new clinical guidance on non-invasive positive pressure ventilation and provided the commissioner with a copy.
The woman’s daughter-in-law, who laid the complaint, was given opportunity to comment on Hill’s provisional opinion.
She stated that several nurses told her that she should complain, and she found this distressing as it indicated to her that NMDHB seemed to rely on “the people most vulnerable” to report problems, and did not have an adequate system for self-investigation to regulate itself without a logged complaint.