Woman who developed sepsis did not receive care of an acceptable standard, says HDC

Assistant Health and Disability Commissioner Deborah James has found the Southern District Health Board failed to provide services of an appropriate standard to a woman who developed sepsis following surgery surgery at Dunedin Hospital.

Deborah James made the decision regarding the care of a woman who suffered a fractured femur in a skiing accident. The woman underwent surgery to repair the fracture, but developed sepsis the day before her scheduled return to her home country.

Blood tests and blood cultures were ordered, but no action was taken on the abnormal results. It took more than ten hours from the time the blood tests were requested for the treatment to be provided to the woman.

Deborah James has concluded that the Southern District Health Board violated Right 4(1) of the Health Services and Disability Consumers’ Code of Rights – the right to have services provided with reasonable care and skill. She says the case highlighted the importance of recognizing and identifying sepsis and taking appropriate action when a patient’s condition deteriorates.

Deborah James felt clinical staff should have postponed the planned repatriation earlier than planned. “Staff failed to obtain the full clinical picture…did not appreciate the risks of continuing repatriation…and failed to take appropriate action as required by the pathway flowchart. ‘escalation of deteriorating patient’s Early Warning Score (EWS), when the woman’s condition deteriorated and her PAS increased’.

The woman also raised concerns about the quality of the clinical documentation on her case. The Southern District Health Board acknowledged that the wording used in the clinical documentation was unprofessional.

The Southern District Health Board has informed HDC that it has made a number of changes since these events occurred. In addition to these changes, Deborah James recommended that the Southern District Health Board issue a formal written apology to the woman; and:

– develop and implement guidelines for the identification of sepsis and for the assessment and management of patients clinically symptomatic with sepsis;

– audit the management of SAP for ten consecutive patients admitted to intensive care for sepsis and present the results at the meeting of clinical directors and the committee for the recognition and response of deteriorating patients;

– provide all nursing staff involved in the care of women with documentation training and undertake audits of their documentation; and

– use this report as a basis for learning for nurses and physicians at the Southern District Health Board.



Editor’s Notes

The full report of this case can be viewed on HDC’s website – see HDC’s’ Latest decisions‘.

Names have been removed from the report to protect the privacy of the person involved in this case. We anticipate that the Commissioner will name DHBs and public hospitals found to have violated the Code, unless doing so would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or consumer. HDC’s naming policy is available on our website

HDC promotes and protects the rights of people using health and disability services, as set out in the Health Services and Disability Services Consumer Rights Code (the code).

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