Under-pressure hospital investigated over man’s death from minor surgeryby Donna Chisholm
The Health and Disability Commissioner (HDC) has launched a formal investigation into the death of Davies five days after he suffered a pulmonary embolism during what should have been routine surgery at Middlemore Hospital in Auckland in April 2017. Fewer than 5% of complaints to the commissioner result in formal investigations.
The hospital has been at the centre of a number of controversies in the past year, most involving rundown buildings with mould, asbestos and raw sewage issues, but also unapproved spending on some building contracts. In April, it was described as “the emblem of what is wrong with New Zealand’s healthcare system”. Last year, police investigated the 2013 death of patient Heather Bills after a “non-accidental” dose of insulin administered by a nurse.
Despite his wound being assessed as requiring surgery within 24 hours of admission, Davies waited almost a week for doctors to debride an infected haematoma on the back of his right calf after communication broke down between the hospital’s orthopaedic and plastics teams. His family say team members had heated arguments in front of him about who should do the operation. The hospital has confirmed to the family that his surgery was not delayed by more acute cases and acknowledged a “temporary miscommunication”, saying “there were a number of areas during Mr Davies’ care where communication and documentation could be improved.”
The delay, during which he was largely immobilised in a leg brace with his anti-clotting medicine withheld because of the pending surgery, put him at high risk of venous thromboembolism (VTE). But he was given no documented clot assessment, and no preventive therapy, until two days before his operation, when it’s likely the embolus had already formed in his leg, from where it travelled to his lungs.
The hospital has apologised to Davies’ family for an experience which “added to their distress”, and says it has taken steps to ensure clear pathways of communication are established and accurately documented after a consultation. The family say they’re going public to draw attention to issues they believe are deep-seated in the public hospital system. “Brian should be with us today because he was healthy and looked after himself,” his widow, Carole, told the Listener. “His death was unnecessary and tragic and we can’t do anything about it, but we can perhaps stop it happening to somebody else.
“Hindsight is a wonderful thing, and on reflection, we should have made a fuss earlier. But because we are reasonable, average folk, and our medical knowledge was only average, you don’t know what you don’t know.”
She suspects he was the victim of a “perfect storm” of circumstances: admitted on Easter Saturday during a holiday weekend, to a busy hospital braced for the start of the flu season. CEO Geraint Martin had resigned to take up a position at Te Papa and Carole Davies believes there was a “leadership vacuum” that meant although policies were in place, they weren’t necessarily followed.
The hospital admission that led to Davies’ death was his second that month. A fit and active man who was a property developer in recent years, Davies had been on dabigatran, a blood-thinning agent, for a number of years because he had atrial fibrillation, a rhythm abnormality in the heart that can cause clots, but was otherwise well. He’d been fixing a cracked board near the roof on his Clarks Beach home in the late afternoon of April 1 when the ladder shifted and toppled. He fell about 2m, landing through the rungs, tearing the quadriceps muscles in his thigh and lacerating his shin from knee to ankle. He hobbled to bed in pain that night, but the next day Carole drove him to the local emergency clinic, which referred him to Middlemore.
The hour-long surgery on April 3 to repair the quad muscle and stitch the cut was uneventful and he was discharged, wearing a leg brace, two days later. Carole Davies says they were told to come back in two weeks for the stitches to be removed, but apart from that, were given no care plan, and no district nursing help was arranged. “I had no idea what to do,” she says. Brian Davies complained to ACC, and later to an orthopaedics registrar at Middlemore. “My neighbour, who’s a nurse, said, ‘This is ridiculous’, and organised a district nurse to visit,” Carole says. The nurses changed his dressings, but neither they nor the family took much notice of a small scrape on the back of his calf, at the lower end of the brace, until faint red lines began radiating from it, indicating infection had set in. He was readmitted to Middlemore on April 15.
Davies was kept “nil by mouth” most mornings in preparation for surgery that didn’t happen – the orthopaedic surgeon in charge of his case thought plastics should do the operation, but when an orthopaedic registrar tried to contact a plastics registrar by phone, the person couldn’t be contacted because they were on sick leave. Nursing staff made repeated references to the delays in his notes on successive days: “needs plastics involvement”, “awaiting plastics review”, “plastics to see(!)”, “for plastics input” and “patient frustrated about plastics”. Finally, on April 20, the sixth day of his readmission, they note an “acute plastics review” and the operation – by a plastic surgeon – was finally carried out the following day.
Davies’ daughter, Kim Davies-Haycock, who has led the family’s engagements with the Counties Manukau District Health Board, says her father told them members of the orthopaedic and surgical teams had heated disagreements within his earshot about who should do the operation. “One of them said words to the effect, ‘I’m not f---ing responsible.’” Her father told them the orthopaedic surgeon was aloof and not easy to communicate with.
Carole Davies says her husband told her the two teams were “at each other” about who should operate on the wound, about 3-4cm in diameter. She was present during one “cross” exchange, on about the third day of his hospitalisation. “One said, ‘Well, who’s going to be doing this then?’ And Brian’s lying on the bed and I’m sitting there thinking, ‘You don’t really expect to hear this in hospital.’ But I wasn’t privy to who was talking to whom because they don’t wear name tags. In hindsight, you think, ‘Why didn’t I make a fuss about it?’ Why didn’t I say, ‘What the hell is going on here?’”
Davies was without any therapy to prevent clotting for five days. Middlemore says the orthopaedic surgeon acknowledged Davies had risk factors for a deep vein clot, but said there were also indications for not using prophylactic treatment. These included the fact he was “mobile” – which the family say he was not – and concerns about further infection, wound-ooze and bleeding from his haematomas. Those reasons are not documented in his notes. Davies-Haycock says she had no idea how vital it was for her father to keep his legs moving while he was bedridden.
The health board, in a response to a request for comment from the HDC, says the orthopaedic surgeon “accepts that the documentation of deep vein thrombosis prophylaxis and decisions has not been done well in Mr Davies’ case”. It apologised for the delay to his surgery, and that reasons for it weren’t conveyed clearly to the family, including that antibiotics were needed before debridement surgery. The health board refused to discuss the case with the Listener, saying this was inappropriate while it was still under HDC investigation.
Carole says her husband had complete faith in the hospital staff. “If they said, ‘This is how we are doing it’, that’s how it was. He trusted them; they were the professionals. It was an old-fashioned sort of thing. Whereas I might want to question it, Brian was always, ‘They know a whole lot about stuff that I don’t know about.’” Some mornings, she would have to go to the nurses’ station to seek food, she says, because he hadn’t been fed after the operation was postponed yet again. “He said, ‘Don’t make a fuss, it won’t hurt me to lose a bit of weight.’”
Brian Davies’ hospital notes record he was “handed over to theatre nurse” at 11.05am on Friday, April 21. Carole knew the procedure was fairly minor, and expected it to take only about 20 minutes. She was so relaxed about it, she went shopping – she’d told him on the phone that morning she’d visit when he woke up.
The plastic surgery team was applying dressings after the operation, at 12.35pm, when Davies showed the first signs of a massive pulmonary embolism. His blood pressure and cardiac output began to drop precipitously. Hospital notes record the increasingly frantic efforts to revive him, including doses of adrenalin and clot-busting drugs and six rounds of cardiopulmonary resuscitation. At 1.38pm, Davies, on life support, was transferred from theatre to intensive care.
Carole doesn’t remember who called her or when, only that there was “a panicked phone call from a man at the hospital, who said, ‘Get in here straight away and bring someone with you.’” Unable to raise the rest of the family, she battled Friday- afternoon motorway traffic alone to get to Middlemore. “All I could think was, ‘It can’t be that bad. It can’t be that bad.’”
It was very much worse. “Someone took me to ICU and there’s my darling lying comatose, with stuff attached everywhere. I was so shocked. I thought I’d be bringing him home. I was in a state of disbelief. It hadn’t even occurred to me that this could happen. They were going to clean out a wound. It was minor surgery. That’s why I was so ill-prepared for it.”
For a brief time in the next few days, Davies, surrounded by his family, looked as if he might rally. His sedation was reduced; he started to squeeze their fingers when they held his hand and wiggle his toes on command. “He was intubated, so he couldn’t communicate with us,” Davies-Haycock says. But his increased consciousness came with a distressing side effect. “It looked like he was in agony; he was silent screaming, with awful grimaces.” The sedation was increased again, so upsetting was it for family and staff. In the following days, Davies’ limbs swelled horrifically as his organs shut down. On April 26, a CT scan showed he had sustained extensive brain damage in a massive stroke 48 hours earlier.
Davies-Haycock and her mother drove to the Parnell Rose Gardens and talked about letting him go. They spent his last night with him, playing his favourite music – Leonard Cohen, Bread, Carole King, a bit of Mendelssohn, some Gregorian chants. They sang You Are My Sunshine and told him how much they loved him. Maybe he heard. When he died, at 3.15pm on April 27, it was, his notes say, a calm and peaceful death.
In the months after her father’s death, Davies-Haycock says, it looked as if hospital management really wanted to do the right thing. On August 14, a week after the family laid a complaint with the HDC, they met the health board’s acting chief executive, Dr Gloria Johnson, and chief medical officer, Dr Vanessa Thornton, who said they would set up a taskforce of senior orthopaedic, nursing and physiotherapy staff to ensure “gold standard” assessment of venous thromboembolism (VTE) for all acute patients, and invited Davies-Haycock to join it. Davies-Haycock spent weeks looking into international best-practice, but at the next meeting, on September 18, her hopes were dashed. There would be no taskforce; instead, they had a plan to replace the inadequate and unused VTE assessment sheets and remind staff to do the assessments. They would now put a sticker on each patient’s file.
In December last year, Davies-Haycock met the orthopaedic surgeons under whose care her father was admitted. It wasn’t the healing meeting she’d hoped for. “I told the surgeon that I’d never heard him say to us that he was sorry. He said, ‘I’d like you to know I’m sorry’, but it means nothing when you have to tell someone to do it.”
She says many organisations, including those in the transport and construction industry, must comply with occupational health and safety guidelines, but in hospitals, there appears to be no similar enforcement. “Why can senior doctors disregard written policy for VTE and no one is held accountable?”
VTE prevention is a focus of the HQSC’s safe surgery group, led by University of Auckland professor of surgery Ian Civil. About 2000 patients a year have a VTE in hospital, a third of which are pulmonary emboli. About 60 patients a year die. Civil says they can occur even when everything possible is done to prevent them, but when they happen – and are fatal – in the absence of steps to prevent them, “it is hard to defend”.
When patients on anticoagulants are admitted for surgery, they’re usually withdrawn from those drugs ahead of the operation, because of the risk of bleeding, and either given an alternative, shorter-acting drug such as clexane, or VTE prophylaxis such as compression stockings, foot pumps, or intermittent compression devices that mimic natural calf contractions. Civil says every patient should have a VTE plan documented for them and, without specific contraindications, have a “multi-modal” strategy in place. “Most of us are a bit aggressive on our VTE prophylaxis – literally, everyone gets something.”
The results of an aggressive approach have been positive, he says, with incidence rates of deep vein thrombosis – which describes a range of blood clots, including VTE – falling from about four years ago, when the HQSC began working with district health boards on a prevention programme. The HQSC predicts VTE occurs in about 1% of acute surgical admissions, and about 1% of those are fatal. It estimates that since January 2013, more than 350 pulmonary emboli have been avoided, saving $7.3 million and likely dozens of lives.
But Civil says prevention policies can only take the health service so far. More important is the communication that ensures patients are receiving co-ordinated care. A common problem, illustrated in the Davies case, is that decision-making is often delegated by default to junior people. When the orthopaedics team wanted the plastics team to review and operate, a registrar was delegated to set that up by phoning another registrar, but when that doctor was sick, the messages went unanswered.
A former army surgeon, Civil says that in the military, “you always have the most senior people making the most important decisions. Is this person sick or not? Should this person have an operation or not? Should this person go home or not? You get the senior people to make those decisions and the less senior people to do it. In the health system, we seem to have the reverse philosophy. Calls from GPs, who are often very experienced, are taken by the most junior members of staff, who can act like a wall and give them the third degree about what they’ve done or not done and maybe send it to another specialty. A senior person would say, ‘Send them in, we’ll sort it out for you.’ If a consultant calls me up, I’m going to specifically do something, whereas letting junior people talk to other junior people, it can get lost in translation.”
Two senior doctors who’ve seen details of the case but did not want to be named called Brian Davies’ treatment “very poor”. One said the notes portrayed “complete dysfunctionality” of the medical teams. “Things like this really annoy me,” he said. “People didn’t talk to each other at a high level, and weren’t patient-focused. When I come in to hospital, I want someone looking after me that I can rely on to have my interests at heart and in this I can’t see that anyone was totally responsible.
“There was endless delegation – delegation up and down within the orthopaedic team, delegation of junior people to call plastics. No one said, ‘If this was me and I was Mr Davies and I had fallen down a ladder, what would I want to have happen? I know darn well what I would want and I don’t see it happening in these notes.”
“They didn’t recognise what a high risk he was for a VTE,” said the second doctor. “Surgical services tend to be very focused on operating and don’t necessarily have the skillset to manage the problems of someone of this patient’s age.”
In some other hospitals, elderly people admitted with fractured femurs are transferred immediately after surgery to the older people’s health service. “If I ran the place, the surgeons would do the surgical bit but wouldn’t be responsible for the day-to-day care.”
Brian Davies would have turned 80 on July 7 this year. He’d have felt cheated at missing the milestone birthday, Carole reckons. The family are still struggling with the gap he has left. “Sometimes there doesn’t seem a lot of point in life when the love of your life is dead. If he’d died from natural causes, I would have been prepared for it. For God’s sake, we all know we are going to die. He would have said, ‘Well, I had a really good innings’. But he would have been bloody annoyed that he hadn’t been properly looked after.”
Avoiding errors saves money
Adverse events are increasing and not all cases are fully investigated.
Auckland anaesthetist Professor Alan Merry, who has chaired the commission since its launch, says although the figures in the report were “a little simplistic”, and perhaps inflated, “there’s no doubt better-quality healthcare is more cost-effective.”
He says that although healthcare is generally safe, we have a significant harm problem that needs to be dealt with. “But estimates are just that. What’s often not looked at is the net effect of care, so something will go wrong but you still end up better than without it – if you didn’t have the care, perhaps you would have died.”
The number of adverse events reported annually has increased from about 150 a decade ago to more than 500. However, comprehensive investigations are resource-intensive and not all cases result in full inquiries. “But do I think some cases that should be investigated aren’t? I think the answer is yes.”
The commission’s priorities have included reducing falls, surgical site infections and cases of deep vein thrombosis (DVT)/pulmonary embolism (PE). Merry says in the latter, the focus has been on ensuring every patient has a plan. “It’s not telling [staff] what that plan should be, as much as saying that people shouldn’t just forget about it – that’s the real problem, when there is no plan.”
In 2012, the VTE Prevention Steering Group released a plan to reduce DVT and PE in hospitals and standardise treatment. In it, Health and Disability Commissioner Anthony Hill said he had reviewed a number of complaints related to deficiencies in venous thromboembolism management and found significant differences in the practices of health boards, and even within wards of the same DHB. The HQSC’s June 2018 report says since January 2013, 351 DVT/PE cases have been avoided (based on predicted estimates), saving $7.3 million.
Patients need to be partners in care.
Kim Davies-Haycock says her father’s death could have been prevented if the family had known to ask a number of basic questions. “Everyone in hospital needs to speak up about their concerns or have someone who can speak up for them. They need to be a partner in their health care, with the hospital. It would have saved so much waste – not just Brian’s life, but a huge cost to the healthcare system of all those people who had to care for him in intensive care, and all those who are now involved in the investigation into his death. It could so easily have been avoided.”
She believes this simple checklist of questions could help families with loved ones in hospital:
- What is the name, occupation and department of those responsible for my health care?
- What is the plan for managing my health problem?
- What can I do to increase my safety in hospital, and why?
- How does this affect my other health issues/medications?
- What do I need to watch out for or be aware of (such as change in symptoms, handwashing and infection control of staff and visitors)?
- When will the agreed treatment start/end?
- What are the risks of my treatment and what are the alternatives?
- When will we know how the treatment is progressing?
- Who do I talk to if I have concerns?
Deep vein thrombosis
Deep vein thrombosis (DVT) is a blood clot that usually occurs in a deep vein in the leg, and may lead to a potentially fatal pulmonary embolism (PE), if a piece of the clot breaks off and travels to the lungs. When DVT and PE occur together, they’re known as venous thromboembolism (VTE). DVT warning signs include:
- Pain, swelling and tenderness in one leg (usually calf).
- Heavy ache in the affected area.
- Warm skin in the area of the clot.
- Reddish discolouration or streaks, particularly at the back of the leg below the knee.
- The risk of developing VTE increases tenfold in patients admitted to hospital, with contributing factors being general ill health, malignancy, reduced mobility and poor fluid intake, as well as surgery, particularly orthopaedic surgery.
- VTE occurs in about 1 per 1000 of the population and the risk increases with age.
- About 25-50% of VTE events occur in hospitals, affecting about 2000 patients a year. Approximately one third will be a pulmonary embolism.
- About 10% of pulmonary embolism cases are rapidly fatal, killing about 60 patients a year.
Source: National Policy Framework: VTE Prevention in Adult Hospitalised Patients in NZ, 2012
This article was first published in the September 22, 2018 issue of the New Zealand Listener.
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