Health NZ breached patient rights of man who died of sepsis in Auckland City Hospital

• A patient died of sepsis after delays in treatment at Auckland City Hospital, despite his daughter raising concerns he was deteriorating
• Deputy Health and Disability Commissioner Vanessa Caldwell found multiple failures in recognising and escalating care
• Health NZ apologised to the family and implemented improvements for patient care and staff communication.

A patient had no support person with him when he was told he was dying of sepsis, after a series of failures and delays in providing potentially life-saving treatment at Auckland City Hospital.

His widow has told a Health and Disability Commissioner's (HDC) investigation that this would have been a "very frightening experience" for her husband.

The man in his 50s, identified only as Mr A in an HDC report, died just over a week after receiving a stem cell transplant for blood cancer.

The report says his progress following his treatment in 2020 was as expected for the first eight days, but then he rapidly deteriorated, and he died.

"I am concerned that several opportunities to recognise Mr A's deterioration and to escalate his care were missed," Deputy Health and Disability Commissioner Vanessa Caldwell said in a report released today.

Family's concerns not heeded

She also said that clinical staff failed to listen to Mr A's family's concerns as his condition went downhill.

She found that Mr A's patient rights were breached in relation to his standard of care in the 24 hours before he died, and in the way clinical staff were working together.

Caldwell's report quoted an independent adviser, Dr Peter Ganly, who said that Mr A's deterioration was not recognised, and this delayed the start of potentially life-saving antibiotic therapy for 12 hours.

"During the afternoon, evening and first part of the night of [before he died the next morning], successive handovers of this patient occurred through the many layers of the hospital system; between one nurse and another, between one doctor to another ... as is common in the overcrowded, overworked healthcare system which we have in New Zealand today," Ganly said.

"This is a whole-of-system failing," he said.

"A good result depends on communication between individuals of all disciplines up to the most senior and experienced level, and there were several places during [the final day] where this broke down."

Caldwell's report shows the man's daughter, who had experience as an emergency medical technician, was raising concerns about her father's deterioration from 11am on the day before he died.

He was finally admitted to the hospital's Department of Critical Care Medicine (DCCM) at 2am the following day, and died about 8am.

Critically ill and dying

When he was in the DCCM, a senior medical officer recognised that Mr A was critically ill and dying, and that no intensive care treatment would save him.

The senior officer decided to provide palliative care while keeping Mr A conscious enough to allow time for his family to arrive and spend time with him.

Caldwell said that Mrs A, the man's wife, told her that "Mr A did not have a support person with him when they told him he was dying, and she considered that this would have been a 'very frightening experience for him'".

Mr A's daughter had felt something was "really wrong with him" when she visited her father from 11am the previous day.

He had rapid breathing, a high heart rate, low oxygen levels and was unable to keep his eyes open for more than 30 seconds at a time.

The daughter felt his condition should have been monitored much more closely and should have been sent to the High Dependency Unit.

But clinical staff repeatedly told her that further intravenous fluids would help, and that the stomach pains and severe bloating he was experiencing were due to diarrhoea.

"I was repeatedly told he would come right ... after having the next bag of fluids, then the next bag, then the next," the daughter said.

"He didn't improve one bit."

Caldwell said that Mr A's daughter raised concerns with staff multiple times, but these did not appear to have been documented in patient notes.

Caldwell said that Health NZ staff clearly failed to recognise and manage Mr A's sepsis early, leading to a delay in him receiving antibiotics for about 12 hours.

She said the early administration of antibiotics in neutropenic sepsis (where the body has too few infection-fighting neutrophil white blood cells) is "frequently life-saving".

An "adverse event review" of the man's case found there was a delay in recognising sepsis when the man had no fever, resulting in a delay in giving him antibiotics.

There were also "multiple occasions" where action and escalation specified in a mandatory pathway did not occur, and senior medical and nursing staff were not kept informed.

Health NZ apologises 'unreservedly'

Caldwell told Health NZ to provide a formal written apology to the man's family. The agency said it had apologised "unreservedly".

Caldwell also wanted to see new or updated policies, guidelines and processes on sepsis, escalation of patient care, and handover between clinical staff.

She said Health NZ should use this case as a basis for developing education and training on these factors.

She also commended Health NZ for a "robust and comprehensive review" of what had happened and their response.

A Health NZ spokesperson said the agency recognised the deep impact the death had on the man's family and friends.

"We have unreservedly apologised to this whānau for failing to meet the standard of care we expect to deliver for patients and their whānau," the spokesperson said.

"We acknowledge the Health and Disability Commissioner's findings and recommendations and have made wide-ranging improvements to support the safe care of patients in a similar situation."

* This story originally appeared in the New Zealand Herald.