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Report released on hospital care of young man with sepsis in New Zealand

Sepsis, bacteria in blood. 3D illustration showing rod-shaped bacteria in blood with red blood cells and leukocytes

Deputy Health and Disability Commissioner Rose Wall today released a report finding a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the care of a man who presented to a public hospital Emergency Department (ED) with sepsis.

The man, aged in his twenties at the time, arrived at the ED by ambulance. He had a history of Crohn’s Disease, and had been increasingly unwell in the days leading up to his presentation at ED.

The man met the criteria for sepsis, but no antibiotics were charted by either the ED team or the General Surgery team. The ED, General Surgery, and General Medicine teams all had a different understanding as to which team was responsible for the man’s care.

After nearly six hours in ED, the man was transferred to the Medical Assessment and Planning Unit (MAPU). Following his admission to MAPU he was not assessed by a medical registrar, as per the DHB’s policy. At this time, the General Medicine team’s understanding was that the man was under the care of the General Surgery team.

The man deteriorated in MAPU, but did not receive a medical review until his family contacted the medical consultant themselves later that day. The consultant reviewed the man and noted obvious features of sepsis. He immediately commenced IV fluids and antibiotics.

Deputy Commissioner Rose Wall found that after the General Surgery review at around 10.30am, no team took responsibility for the man’s care until 5pm. The clinical staff at the DHB did not co-operate effectively with one another to ensure that the man received quality and continuity of services. Ms Wall also found that the man did not receive timely medical review; the sepsis policy was not followed; written policy for MAPU was lacking; the admission process to MAPU was not followed; and documentation by nursing staff was poor.

“Sepsis is a potentially life-threatening condition that necessitates prompt and at times aggressive treatment,” said Ms Wall. “As a consequence of the above failures, [the man] was left in pain, with no specified person taking responsibility for his treatment, for a protracted period of time, and there was a significant delay in arranging medical review and appropriate treatment. It was fortunate for [the man] that his family took an active approach and sought a review from the doctor directly – otherwise [he] may have deteriorated further.”

The Deputy Commissioner made a number of recommendations to the DHB, including that it audit compliance with its new MAPU and sepsis policies; provide evidence that it has educated its nursing staff about the sepsis pathway; and that it use HDC’s report as a basis for staff training. Finally, Ms Wall recommended that the DHB apologise to the man.

The full report for case 18HDC01768 can be found on the HDC website.

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