Executive summary
This report considers the care provided to a man in his early fifties who was discharged from the Emergency Department of a public hospital with an undiagnosed pulmonary embolism.
During his time in the Emergency Department, despite being assigned a triage 3 priority categorisation, having an elevated troponin level, and requiring a repeat ECG, the man waited several hours for a medical assessment.
The house officer who assessed the man failed to consider pulmonary embolism as a diagnosis, and did not follow the DHB’s Accelerated Chest Pain Pathway.
Owing to a shortage of staff and a high number of admissions to the Emergency Department, the house officer was not supervised adequately by senior medical staff. The man was not reviewed by senior medical staff before being discharged home.
Approximately five and a half hours later, the man collapsed at home and was taken back to the Emergency Department by ambulance. However, he suffered a cardiac arrest and died.
Findings
The Commissioner found that MidCentral DHB breached Right 4(1) of the Code by failing to:
a) Consider a pulmonary embolism as the cause of the symptoms;
b) Order a repeat troponin test and a further ECG;
c) Undertake a medical assessment in a timely manner;
d) Consider a differential diagnosis;
e) Think critically when the case was discussed at handover and with senior staff;
f) Ensure that an adequate medical assessment was undertaken;
g) Ensure that the house officer was supervised adequately by a senior medical officer;
h) Document patient history and clinical decision-making adequately; and
i) Ensure that there were adequate resources available to staff to enable them to meet the standard of care required in an emergency department in New Zealand.
Recommendations
The Commissioner recommended that MidCentral DHB audit the Emergency Department waiting times to check whether the times correlate to the triage code ascribed to presenting patients; provide an anonymised case study to staff for the purpose of staff training; and provide training to Emergency Department medical staff on diagnosis of pulmonary embolism, documentation, and supervision of junior staff.
The Commissioner also recommended that MidCentral DHB provide a concrete plan for corrective action on the issues identified by the independent report commissioned by the DHB and apologise to the family.
Read the full report here.
