Poor Staffing Criticised For Death Of Elderly Woman In Ōamaru

Tess
Brunton, Otago/Southland reporter

The
health watchdog has criticised inadequate staffing at
Ōamaru Hospital’s emergency department after investigating
the death of an elderly woman.

The 93-year-old was
given the wrong amount of saline as a result of a
prescribing error in November 2023.

Deputy Health and
Disability Commissioner Carolyn Cooper said while she was
concerned about the care provided to the woman after
multiple errors by different staff, a postmortem found the
prescribing error did not cause her death.

“While I
acknowledge that individual staff were involved, I consider
that the workload at the time meant that staff could not
carry out their respective roles adequately,” she
said.

Cooper found Waitaki District Health Services,
which managed the hospital at the time, bore the
responsibility of ensuring safe staffing and had breached
the woman’s right to health care that minimised the
potential harm and optimised her quality of life.

“I
am critical that the ED (emergency department) did not have
adequate staffing levels to manage high patient numbers and
that this had an impact on the standard of care provided to
Mrs A by multiple staff,” she said.

Cooper recommended
Waitaki District Health Services apologise to the woman’s
family and noted the organisation had continued to recruit
and employ more staff and boosted training for nursing staff
on the infusion of IV fluids.

She said Waitaki had
guidelines in place relating to saline but steps had been
taken to make the information more widely
available.

A sole doctor on a busy emergency
department night shift

The woman was seen by a
hospital doctor who diagnosed her with pneumonia, urinary
retention and severe hyponatraemia, or abnormally low sodium
levels in her blood, in November 2023.

He prescribed
her 100ml of three per cent saline at a rate of 200ml per
hour before his shift finished and a different doctor took
over her care.

Waitaki District Health Services
acknowledged to the commissioner that the emergency
department was busy.

“Dr C was the sole doctor
covering Ōamaru Hospital on night shift and was responsible
for all ED patients, the acute medical/ward patients,
arranging transfers, speaking to consultants at Dunedin
Hospital, and taking phone calls from nursing homes, as
Ōamaru Hospital provides all urgent care to the region
after hours,” the report said.

A registered nurse
found a 1000ml bag and showed it to a nursing student, who
told him the chart was wrong and it should read 1000ml not
100ml.

The night shift doctor prescribed a 1000ml bag
to run over 10 hours because he believed it was a more
cautious approach and asked for her levels to be checked in
a few hours.

The doctor acknowledged he was not overly
familiar with prescribing the saline solution and told the
commissioner that there were no hospital guidelines and
staff had not raised any concerns about his
decision.

Staff noted there was an audible crackle
while she was breathing but her condition did not appear to
have deteriorated and she was alert.

It was not until
the night shift doctor checked her sodium levels just before
the morning handover that he realised the rise was too
rapid, telling nurses to stop her fluids
immediately.

When her original doctor arrived at work,
he realised the error and started reversing the sodium
correction but the woman soon became unresponsive and
died.

A postmortem found she died from pneumonia and
sepsis and the sodium correction had not been too
rapid.

Cooper raised concerns about the night shift
doctor’s actions because he prescribed the larger saline bag
despite being unfamiliar with the solution and did not look
up the hospital’s guidelines.

“Severe hyponatraemia in
a severely ill elderly respiratory patient is such a red
flag, and ultimately Mrs A’s care was the responsibility of
Dr C despite his suggestion that staff did not raise
concerns on reading his prescription,” she
said.

Cooper said the woman’s treatment was a moderate
departure for the accepted standard of care because the
prescribing error was not responsible for her death and the
workload was “at the limit of what can be considered
safe”.

She also criticised the shift leader and
nursing student who administered the dose despite concerns
the prescription was incorrect, saying the shift leader did
not adequately supervise the student.

Cooper found the
woman’s deteriorating condition might have been noticed
earlier if her vitals had been better assessed and
documented.

She recommended Health New Zealand
Southern, which took over operations at Ōamaru Hospital in
July 2024, provide training for emergency department staff
and rural hospitals on managing abnormally low sodium
levels, update the commissioner on staffing levels, confirm
different saline bags were kept in separate places and show
it was improving its
documentation.

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