Taranaki DHB's 'collective failure' preceded heart attack victim's death, watchdog finds

The Taranaki District Health Board has been found to have provided a very poor standard of care to an elderly man following a heart attack.

In 2015, the 68-year-old man was admitted to the emergency department of a public hospital, where blood tests and an electrocardiogram showed that he had suffered a heart attack, according to a report released today by Health and Disability Commissioner Anthony Hill.

He was admitted to a general medical ward, where he was monitored through remote cardiac monitoring, and was given blood thinning medications. During this time, the man was also given several sprays of glyceryl trinitrate, which is supposed to relieve chest pain but comes with the risk of falling over.

The man's risk of falling was not properly managed, the report said, and he subsequently injured his head in a fall. When staff were alerted to the man's fall, they did not respond appropriately, the report states, adding that information regarding the man's fall and head injury was known to some staff but not communicated adequately to staff who needed to know.

Blood-thinning medication continued to be administered to the man by some nursing staff, despite being made aware of his head injury and without ensuring his condition had been reviewed by the medical team. When the man's condition began to deteriorate, a medical review had not been sought with clarity, and decisions about the review were not recorded, the commissioner said. 

Later that evening, nursing staff found that the man had vomited, was breathing abnormally and was non-responsive. An urgent CT scan showed a large brain bleed. Following a discussion with his family, the man received palliative care and died in the early hours of the next morning.

Nurse, hospital (file picture). Source:

Mr Hill stated that the while the information required to treat the man correctly was contained within the hospital system, staff failed to do so.

"The system lost sight of the man through this process," Mr Hill said. "Attention to the most basic aspects of monitoring, assessment, communication, and critical thinking were noticeably absent.

"While staff may have been busy, they had the opportunity to consider the care of this patient, and simply failed to do so adequately - this was a collective failure of the system and the people operating in it, not the fault of any one individual.

"Nonetheless, the man's experience resulted from a pattern of poor care, which reflects a sobering collection of suboptimal features."

As a result of the incident, the Taranaki DHB was found to have breached the Code of Health and Disability Services Consumers' Rights.

Mr Hill made a number of recommendations, including that the DHB review its communication tools to ensure accurate handovers between shifts, and evidence of a new alert system flagging patients who are receiving blood thinning medications.

He also recommended carrying out audits to assess whether patients who have experienced heart attacks have been transferred to the critical care unit, as well as whether the electronic notification tool used to contact medical staff was appropriate.