By Anna Sargent of RNZ

A woman died after being dropped from a hospital stretcher at Whangārei Hospital, a coroner has found.

Margaret Batten, 83, suffered a head injury after falling onto a concrete floor in the ambulance loading bay when a St John officer lost control of her stretcher during her discharge in May 2023.

Coroner Tracey Fitzgibbon said Batten was secured on a Stryker stretcher and was in the process of being moved down a ramp by a St John patient transfer service (PTS) officer when she fell.

“As the stretcher started to descend, the left wheel at the head of the stretcher has caught on the wooden kickboard and tipped down towards the loading bay floor. The stretcher has toppled. Mrs Batten landed on her left-hand side on the concrete bay floor,” she said.

“She was assessed by the PTS officer and HCA (healthcare assistant) and taken back to the emergency department for treatment. Mrs Batten sustained a fatal injury and died later that day.

“The cause of death was a traumatic brain injury sustained when she struck her head on concrete.”

The coroner said investigations were carried out into Batten’s death by St John and Health New Zealand, with a WorkSafe inquiry.

“I am satisfied that the cause of the stretcher tipping into the ambulance bay was due to a loss of control by the PTS officer,” she said.

“The ramp was used on multiple occasions for transferring patients to ambulances. No previous incidents have been brought to my attention, and therefore, this was an isolated incident.”

The coroner outlined several contributing factors to Batten’s death, including the fact that the stretcher was meant to be operated by two people.

Hato Hone St John ambulance operations general manager Debra Larsen said Batten’s death had a profound impact on everyone involved. Photo / Jason Oxenham

Fitzgibbon said the loading ramp outside Whangārei Hospital was also unsuitable for the use of Stryker stretchers.

“In hindsight, if the stretcher had two operators, at the foot and head, this likely would not have occurred,” she said.

If the ramp was the new configuration, the stretcher would not have tipped into the ambulance bay. I accept that the PTS officer also had to navigate through works being conducted at the ED entrance.”

Health NZ and St John had made a number of changes since Batten’s death and accepted the coroner’s findings.

“Of note, Hato Hone St John have increased training by two days to focus on the safe operation of stretchers as a single-use operator. This includes manoeuvring in a range of environments and loading/unloading,” the coroner said.

“By 2026, the replacement of non-powered stretchers to powered stretchers will be in place across the country. The powered stretchers are viewed as a safer option for single operators.”

The ambulance ramp reconfiguration at Whangārei Hospital was completed in August 2023.

Health NZ Northland group director of operations Alex Pimm said the organisation was “extremely sorry” about what had happened.

“We thoroughly investigated this incident with Hato Hone St John and have made changes to help prevent a similar event from happening again,” he said.

Whilst there were no formal recommendations made in relation to Health NZ’s clinical care, we have implemented recommendations from our internal review to improve safety when transferring patients between hospital and a patient transfer ambulance.

“These changes include regular meetings with Hato Hone St John regarding shared use facilities, improved systems for reporting concerns or issues with our facilities, and modifications to the ambulance bay ramp to improve patient safety.

“We have also developed a transit lounge where patients can be collected by ambulance for transfer to their home, which has purpose-built facilities and reduces traffic in the emergency department ambulance bay.”

Hato Hone St John ambulance operations general manager Debra Larsen said Batten’s death had a profound impact on everyone involved.

“We remain committed to learning from it and improving the safety of our services,” she said.

“Most of the recommendations have been completed or are under way, including working with Health NZ to improve the ramp and railings at Whangārei Hospital, establishing a formal communication system between Health NZ and Hato Hone St John to better manage overlapping safety responsibilities, refreshed training for staff involved in stretcher use, dynamic risk assessment training for single-crewed Patient Transfer Service (PTS) staff, carrying out risk assessment reviews of ambulance loading areas across NZ, and strengthening the content and guidance within Patient Transfer Service regional handbooks.

“We would like to reiterate how deeply sorry we are for what occurred and extend our sincerest condolences to Mrs Batten’s family.”

-RNZ