Death of mother following surgical delay and multiple care failures – report

Having already waited nearly 12 weeks for surgery she should have had within four years, a Taranaki woman was taken by her desperate family to hospital – only to die two days after the operation.

The delay in surgery and multiple other failures by the Taranaki District Health Board (TDHB) in caring for the woman led to her death, a Health and Disability Commission (HDC) report has revealed.

In 2019, the woman, known as Ms A in the report, visited Hāwera Hospital with severe abdominal pain and was transferred to Taranaki Base Hospital, where she underwent surgery. surgery for kidney stones.

After the surgery, a referral was sent for the woman to be placed on the waiting list for ureteroscopy lithotripsy to treat the kidney stones.

She was due for this operation within four weeks.

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However, almost 10 weeks later, she had not even received a date for the operation.

In pain, she returned to Hāwera Hospital and was admitted overnight. Although she was still in pain, she was released the next morning.

A week later, she had a follow-up appointment, but still hasn’t received a date for her surgery.

The following week, the woman, in her 60s, returned to Hāwera Hospital with “unbearable” pain. She was released the next day, still without an operation date.

A week later, the woman was taken to Taranaki Base Hospital by her husband and son as they were ‘fed up’ with the continued pain she was in and the lack of progress in securing a date for his operation.

Her condition was now “acute” and she was operated on the following day.

After the operation, the woman’s condition worsened, she developed sepsis and died in hospital two days later of fungemia – the presence of yeast or fungi in the blood.

In a report posted on the HDC website this month, Deputy Commissioner Deborah James said the TDHB had failed to provide services to the woman with reasonable care and skill.

James said the time the woman waited for her second surgery was beyond the scheduled four weeks and beyond the reasonable tolerance of eight weeks.

She also said appropriate escalation in response to her Early Warning Score (EWS) was repeatedly not taken, there were instances where appropriate professional concerns from nursing staff regarding her condition appeared not to have been taken into account and answered by the doctors of the TDHB. , and there was a lack of experienced medical personnel involved in his care.

These failures were not the result of isolated incidents involving one or two members of staff – they started when she was referred for her follow-up operation and involved at least six different members of staff, doctors and nurses, James said in the report. .

As a result, the TDHB was found to have violated the Health and Disability Services Consumers’ Rights Code.

The DHB told HDC that it has only one full-time urologist and “even with two full-time urologists employed in 2021, it remains a challenge to operate within Health Department guidelines.”

The TDHB accepted the ruling but asked that the matter not be escalated to the director of proceedings, who may consider further action, saying it had already implemented the recommendations made by the commissioner.

However, in his report, James said that “the numerous failures in this case paint a very concerning picture at a systems level, and that there is a strong public interest in holding TDHB accountable for the failures identified in the services it has provided”.

TDHB has since engaged with external providers – the New Zealand Sepsis Trust and the Health Quality & Safety Commission – to support the implementation of an identification and management program to improve the treatment of sepsis in his patients.

The TDHB, now known as Te Whatu Ora Taranaki, has been approached for comment.