Lack Of Recognition Of Deterioration In Patient Following Bowel Perforation

The need to recognise a patient’s deteriorating
condition and provide appropriate intervention was
highlighted in a decision published by Health and Disability
Commissioner Morag McDowell.

Ms McDowell found a
consultant surgeon in breach of the Code of Health and
Disability Services Consumers’ Rights (the Code). Her
decision emphasises the importance of critical thinking when
re-assessing a patient and reviewing the diagnosis and
management plan.

A man, aged in his seventies, had a
number of health issues. He underwent a colonoscopy at his
local district health board (DHB) during which a number of
polyps were removed. He presented to hospital the day after
the colonoscopy with abdominal pain, and an x-ray suggested
his bowel was perforated. The clinicians at the local
hospital considered the man was too high risk to be managed
at their DHB due to his existing medical conditions and the
likely need for intensive care following surgery.
Arrangements were made for the man to be transferred to a
larger hospital, at another DHB, for further care. Before
the transfer, a CT scan was taken that again showed a likely
bowel perforation.

On arrival to the larger hospital,
the man’s condition was stable. The surgical team made the
decision to treat him conservatively, without surgery, as
surgery was likely to be difficult and complex due to the
man’s existing medical conditions. Over the next two days,
the man’s condition deteriorated. When the consultant
surgeon reviewed the man during a ward round on the third
day, he did not identify any deterioration and so the plan
for conservative treatment was maintained. On the fourth
day, the man’s condition worsened and he underwent urgent
surgery, which showed extensive faecal contamination from a
hole in his bowel. Sadly, he died soon after surgery from
septicaemia.

With reference to clinical advice, Ms
McDowell accepted that the initial decision to trial
conservative management of the man on admission to the
larger DHB was reasonable, and a continuation of that plan
was cautiously appropriate when he was reviewed the next
day.

However, Ms McDowell considered that when the
consultant surgeon reviewed the man on the third day, there
was a missed opportunity to recognise the man’s
deterioration and intervene with surgery at that
time.

“I acknowledge that the signs of sepsis were
subtle and non-typical. However, it is well documented in
the clinical notes that in the preceding 24 hours, the man
had multiple reviews indicating that he was not well. Based
on this, and the expert evidence, a deterioration in the
man’s condition is evident,” said Ms McDowell.

Ms
McDowell acknowledged that staff did not volunteer any
information to the consultant surgeon of any changes in the
man’s condition. However, she noted that it was the
responsibility of the consultant surgeon during the ward
round to elicit relevant information from his more junior
colleagues.

Ms McDowell considered the errors that
occurred were the result of individual clinical judgement,
and did not indicate broader systems or organisation issues
at the DHB, and therefore did not find it in breach of the
Code. However she was critical of several aspects of the
man’s care in relation to the delayed medical review,
documentation, escalation of care and
communication.

Ms McDowell recommended the consultant
surgeon provide a written apology to the family.

Ms
McDowell also recommended the larger DHB provide training on
documentation to junior staff in the Surgery Department,
consider a review of the training provided to junior doctors
on escalation following multiple reviews of a patient, and
consider developing a guideline for documentation of patient
handover. She further recommended it provide an update on
the changes made as a result of these events, including the
education provided to relevant staff on decision-making and
sepsis, and the development of a sepsis programme.

Ms
McDowell further recommended the man’s local DHB provide
an update on the changes to their procedures made as a
result of these events, and the larger DHB upskill and
mentor the man’s local DHB’s endoscopy service in
polypectomy technique and assessment of polypectomy
sites.

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