Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
- On 15 November 2021 this Office received a complaint from Mrs A about the care provided to her husband, Mr A (aged 78 years at the time of the events), at Health New Zealand|Te Whatu Ora (Health NZ) Capital, Coast and Hutt Valley.
- Mr A arrived at a public hospital’s Emergency Department (ED) by ambulance on the morning of Monday 27 September 2021 following a fall at home the previous night, in which he injured his neck and was experiencing breathing difficulties. Mr A was admitted to the Intensive Care Unit (ICU) after a specialty team examined him in ED. A CT scan was booked but was not performed because Mr A was unable to lie flat due to worsening stridor. The intention was to rebook the CT scan later that day, if still required. Mr A’s airway swelling and breathing improved during the day, so a CT scan was not rebooked. Mr A was discharged from ICU the following day. Mrs A said that when her husband was admitted to ED, she mentioned his ankylosing spondylitis.
- On Saturday 2 October 2021 Mr A was referred to the public hospital’s ED by a medical centre with worsening right shoulder pain and suspicion of pneumonia (he had a fast heart rate and had been on antibiotics for a chest infection). Mr A was assessed by an ED doctor and an orthopaedic registrar, and an X-ray was taken of his shoulder (the reported site of his pain), but no fracture was found. No further investigation was recommended, and Mr A was discharged home with codeine.
- Mr A was in intensifying pain for over a month, until his GP referred him for an X-ray. An unstable C6 fracture was discovered at this point, and Mr A was transferred to hospital for emergency surgery.
- Mrs A raised concerns that a holistic approach was not taken in examining Mr A and that it took over a month to make this diagnosis and treat the injury, during which time he was in significant pain and distress. A review by the geriatric team was not recommended, and Mrs A feels that she was not listened to, particularly in ICU when the decision was made to discharge Mr A a day after admission. Mrs A raised concerns that Mr A had ‘cognitive deficit’, which was communicated to staff, and this should have resulted in more advice and information being sought from her when Mr A was experiencing confusion.
- Health NZ completed a System Analysis Review (SAR), which found that gaps in the care provided to Mr A resulted in the fracture being missed. In summary, Mr A’s fall was not seen as significant trauma, so his treatment focused on the soft tissue injury and breathing difficulties. The review found that there was a lack of recognition of Mr A’s complex care needs and the need for multi-disciplinary planning in his discharge from ICU to his home. In addition, ICU and ENT failed to consider the ‘bigger picture’ of Mr A’s presentation adequately, in that they lacked a holistic approach.
- Mrs A was given an opportunity to comment on the provisional opinion. Mrs A said that she is happy that the process is coming to its conclusion and she feels validated to some degree.
- Health NZ was given an opportunity to comment on the provisional opinion. Health NZ advised that it accepts my proposed findings, recommendations, and follow-up actions.
- Independent advice was obtained from emergency medicine specialist Dr David Prisk (Appendix B). Dr Prisk advised that the focus on Mr A’s airway management was appropriate. However, Dr Prisk was disappointed not to see a documented assessment of Mr A’s cervical spine in the clinical records. Dr Prisk also commented on the lack of a tertiary survey.
- Independent advice was also obtained from orthopaedic surgeon Dr Thomas Geddes (Appendix A). Dr Geddes considered that the physical examination of Mr A was adequate but noted some gaps in the clinical documentation regarding review of Mr A’s range of motion. Dr Geddes also noted that the threshold for obtaining imaging of the neck (with plain X-rays or a CT scan) should have been relatively low given Mr A’s medical history. Dr Geddes advised that during Mr A’s admissions to the public hospital on 27 and 28 September and 2 October 2021 there were several occasions on which imaging of his cervical spine might have been considered.
- On 16 July 2024 I notified Health NZ of HDC’s investigation and proposed that HDC adopt the findings of Health NZ’s SAR and the independent advice received by HDC as the basis for establishing a breach of Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code) in relation to the care provided to Mr A. I proposed this finding as Health NZ acknowledged that there were gaps in the care provided to Mr A that resulted in the fracture being missed. I also took into consideration the identified areas of improvement and the changes made by Health NZ as a result of these events. On 18 December 2024 Health NZ accepted HDC’s proposed breach finding.
- My opinion is that all the teams involved in Mr A’s care failed to consider his complex needs adequately and apply a holistic approach, recognising Mr A’s frailty and underlying health conditions during their assessment. I am also concerned about the inadequate coordination of Mr A’s care and the failure to have Mr A reviewed by the geriatric team. As such, I find Health NZ in breach of Right 4(1) of the Code.
- Health NZ advised that the following changes have been made since the events:
- The ICU has implemented an evidence-based Adult Cervical Spine Imaging and Clearance in Trauma Policy to ensure a consistent approach to assessing and managing the cervical spine in blunt trauma patients, with a particular focus on the elderly and those with known or suspected conditions affecting the spine.
- The Regional Trauma Committee’s Trauma Tertiary Survey Guidelines have been updated by ED staff to include a modified nexus rule to allow for a lower threshold for spinal imaging on elderly patients and to acknowledge existing or suspected spinal pathology.
- Ongoing education on neck injuries is provided to registrars.
- The approach to managing trauma in elderly patients has been updated, with these changes incorporated into the Trauma Tertiary Survey Guidelines.
- A senior geriatrician was invited to the ENT Department monthly meeting to discuss frailty in the elderly.
- A senior orthopaedic medical officer addressed ankylosing spondylitis in frail elderly patients during an education session with the ENT service. The presentation was also given to the ED.
- These events have been used as part of an ED Morbidity and Mortality session dedicated to elder trauma and hidden spinal injuries.
- The ICU completed a quality improvement programme focused on tertiary surveys, including a qualitative study to identify barriers to assessment completion. The programme features an ongoing educational initiative with online training for registrars and the introduction of new documentation to standardise tertiary surveys for trauma patients across the hospital.
- The Orthopaedic Department has increased its ongoing education with respect to neck injuries.
- These changes indicate that Health NZ took responsibility for the errors identified in the SAR to prevent a similar incident occurring. I am satisfied that the issues contributing to Mr A’s delayed diagnosis have been identified by Health NZ and that appropriate improvements have been implemented.
- Further to the changes made by Health NZ, I recommend that Health NZ provide a written apology to Mrs A and her family for the deficiencies in Mr A’s care. The apology is to be sent to HDC, for forwarding to Mrs A, within three weeks of the date of this report.
- I recommend that Health NZ provide further information to HDC on the implementation of an ICU policy to avoid the discharge of elderly patients directly home from ICU. Evidence of its implementation, or an action plan for its implementation, is to be provided to HDC within three months of the date of this report.
- I recommend that Health NZ use this report as a basis for training staff on the importance of involving family and guardians of elderly patients and those with cognitive decline in important conversations regarding their care to ensure a safe and reliable transfer of information. Evidence of this is to be provided to HDC within three months of the date of this report.
- An anonymised copy of this decision (naming only Health NZ Capital, Coast and Hutt Valley and the advisors on this case) will be placed on the HDC website (www.hdc.org.nz) for educational purposes.
