By Lee Scanlon of 
Licelie Lozano with her husband Leo. Photo: Supplied
A review into the death of Filipino carpenter Leonides Lozano, 51, at Te Rau Kawakawa/Buller Hospital in July has found no fault with hospital staff.
However, the nurses and sole doctor were under the pump when Lozano sought treatment. They had eight patients, including an acute heart attack patient needing treatment and transfer, and three more patients with potentially serious medical conditions.
The review said that while Lozano received proper care and attention, in a less stressful environment his high blood pressure might have been viewed differently. Also, more recordings might have been performed and an ECG considered - although it might have been normal.
An ultrasound would have detected an enlarged aorta (main artery) or free fluid in his stomach. But it would probably have found no signs of the aortic aneurysm which would lead to his death, said the review.
Lozano's death has left his wife, Licelie, and their four children in the Philippines without their husband, father and sole breadwinner. Licelie Lozano said she still had many questions.
"I mean, why they gave Leo only paracetamol, diclofenac, Pink Lady (an antacid) and a take-home medicine of omeprazole - with a blood pressure of 198/100."
Leo Lozano went to Te Rau Kawakawa (TRK) at 8.30am on July 17 with stomach and back pain. His pain score was nine out of 10. His blood pressure was 195/102. Other recordings were normal, the review said.
He received painkillers and antacid medication, was monitored and had a blood test. He told staff he had had a gastric ulcer about 10 years ago, but this pain was different.
The result of another blood pressure test at 10.20am was 198/100. His pain had come down to 6/10.
Lozano was diagnosed with gastritis (stomach lining inflammation). His pain eased and he had lunch.
He was discharged at 1pm with a prescription for omeprazole (for stomach acid) and told to return if he got worse.
About 5.20pm Lozano collapsed at home. His friends rushed him back to TRK. They arrived at 5.55pm. A registered nurse got him inside and began CPR.
"Mr Lozano was unresponsive, cold and clammy, not breathing and had dilated pupils," the review said. "Two more RNs and the doctor came to assist with resuscitation efforts and the St John Ambulance team were called along with the Fire Service (FENZ).
"The ambulance crew and FENZ crew were on site by 18:08 and resuscitation efforts continued for 55 minutes.
"During this time Mrs Lozano was contacted and able to video link and observe the CPR and talk to Leo."
An ultrasound scan indicated either a ruptured ulcer or a ruptured main artery.
Leo Lozano was declared dead at 6.55pm.
The review praised the resuscitation effort. "An experienced CPR trainer was on site and the clinical team were all proficient in providing advanced life support. The use of St John Ambulance and FENZ teams is a feature of the smaller rural community where the different services all support each other to deliver care."
A subsequent autopsy confirmed Lozano's main artery had ruptured and blood had poured into the tissue around his heart. He could not have survived.
The review said aortic dissection was rare and had a very high death rate, as did surgical treatment for it. It was often misdiagnosed. "The sudden onset of severe chest pain or back pain which then subsides, is a consistent presenting symptom."
TRK had none of the equipment which could reliably detect it. A full blood count might indicate blood loss. This was now available at TRK but was not available when Lozano was there.
Lozano was not registered with a local general practice, so information about his medical history and medication was not available to the clinical teams. Lozano had been unable to list the blood pressure medications he was on. He had not taken any that day. It would have been easy to see the high blood pressure readings as a variation on his normal readings, the review said.
His blood pressure was not taken before he was discharged.
"If there was concern that Mr Lozano was not having his blood pressure managed by a health professional, then this may have raised a red flag and further treatment and/or investigations may have been undertaken.
"In a similar way, if a discharge blood pressure was high, then this may have raised concerns."
The review said there was an opportunity for Health NZ to link in with local employers and community groups to reassure migrants about getting medical care.
The reviewer, medical lead patient quality and safety Dr Graham Roper, recommended the review be completed following discussion with the Lozano family and clinical review.
Patient Voice Aotearoa chair Malcolm Mulholland said there were "red flags" in the draft review. Clinicians might have done more had they not assumed Lozano's high blood pressure was normal for him, Mulholland said.
"I think we need to be very clear when it comes to clinical practice about what is the standard operating procedure around people who present with extremely high blood pressure. It seems to me that there are no guidelines in place."
Mulholland said it was also clear the TRK doctor was working in a highly stressful environment when Lozano presented.
"We are still no wiser when it comes to a clinician/patient ratio - what that should look like in a facility like Te Rau Kawakawa."
He wants to know what Health NZ (HNZ) has done to prevent a similar tragedy.
HNZ launched a Serious Incident Review soon after Lozano's death but did not inform his widow about it until October 30. It contacted her just hours after Mulholland urged Health Minister Shane Reti to intervene. Reti told HNZ he expected it to engage "appropriately and compassionately" with Licelie Lozano.
HNZ claimed it had had difficulty obtaining her contact details.
Mulholland said today that if HNZ had contacted Mrs Lozano earlier, it might have resolved some of the review's unanswered questions. HNZ's delay contacting her was "appalling" and its reasons for the delay didn't stack up, he said.
The review showed hospital staff had been speaking to her while they tried to resuscitate her husband. "Clearly they had her contact details. It shows Health NZ West Coast to be lacking in compassion," Mulholland said.
HNZ has been contacted for comment.
