Delay in recognition of sepsis following surgery

Executive summary

1. This report concerns the care provided in 2019 to a woman at Taranaki District Health Board (TDHB) following surgery for kidney stones. In particular, the report concerns the delay in obtaining a date for her required follow-up surgery, the delay in recognition of sepsis after the surgery was performed, and the lack of escalation of her care to senior medical staff when she deteriorated.
2. Sadly, the woman died of fungaemia (the presence of fungi or yeasts in the blood) during her hospital admission.

Findings

1. The Deputy Commissioner found multiple failures in the care provided to the woman at TDHB, including not escalating her condition appropriately as per the EWS mandatory pathway, not involving senior medical staff in her care earlier, and the delay by multiple TDHB staff in recognising and responding to her sepsis appropriately. The Deputy Commissioner considered that these failures were not the result of isolated incidents involving one or two staff members — they began at the time the woman was referred for her follow-up surgery, and involved at least six different staff members, both doctors and nurses. As such, she found that TDHB breached Right 4(1) of the Code.

Recommendations

1. The Deputy Commissioner recommended that TDHB provide evidence that all recommendations made in its case review have been implemented; randomly audit whether the Sepsis Ready Programme is being adhered to; provide evidence of its EWS education campaign and roll-out programme for staff; roll out a “speaking up for safety” campaign to all nursing staff, to ensure that nurses are supported, taught, and encouraged to place a 777 call or amplify their concerns around patient management to senior medical staff; consider what further changes TDHB could make to address these concerns and ensure that the professional knowledge and expertise of both nurses and doctors is considered appropriately when decisions are made about care of patients; consider changing the terminology from “pre-arrest” to a term (appropriate for the outreach/PAR system set up at Taranaki Base Hospital) that the teams are more comfortable using; provide an update to HDC on the DHB’s ability to deliver urology surgery within the Ministry of Health Guidelines; and provide a written apology to the family.
2. The Deputy Commissioner referred TDHB to the Director of Proceedings.