A 79-year-old was found unconscious in a Waikato Hospital stairwell, after being missing from a ward for nearly an hour before the alarm was raised.

Soon after he was found, he died.

Now the Health and Disability Commissioner (HDC) has found Health New Zealand Te Whatu Ora breached the Code of Health and Disability Services Consumers’ Rights, in its handling of the man’s medical needs.

The man, referred to as “Mr A” in the decision, had multiple health conditions, including an extensive cardiac history, longstanding memory loss and dementia, a mild cognitive impairment, and type 2 diabetes.

In December 2019, he went to Waikato Hospital’s emergency department with chest pain, accompanied by his wife.

During triaging, the nurse recorded the man had diabetes, but not whether he was on insulin or other medications.

While his blood glucose level was initially measured, there was no further testing while he was in the emergency department (ED), leading his wife to test him herself and administer insulin.

The HDC noted “limited documentation” from ED nurses.

At 2.30pm, on December 29, 2019, the man was transferred to a Coronary Care Unit (CCU), but the HDC noted minimal handover documentation.

Nursing notes recorded he had diabetes, that he was to have a diabetic diet, how often his blood glucose levels were to be tested, and that he was on insulin.

Clinical records indicated that by 11pm, he was unsettled with possible confusion.

A Confusion Assessment Method (CAM) is required when there is a change in behaviour, however, this did not occur.

The next day he had blood glucose testing and insulin administered, but after dinner, at 9.30pm, his blood glucose levels were taken, returning a level of 4.4mmol/L.

The man’s wife told the HDC that her husband would have been unsteady, and his cognitive ability diminished, at a reading as low as 5mmol/L.

The man told the CCU nurse he was concerned about his level, and the nurse went to get him a drink and a sandwich.

But there were no sandwiches in the unit’s fridge, so the nurse went to look in a fridge in another CCU.

When she returned, at 9.44pm, he wasn’t in his bed.

The hospital’s own adverse event review noted that if food had been available in the unit’s fridge, it would have enabled the “rapid provision of food to Mr A” and reduced the risk of him leaving the CCU.

As he wasn’t in his room, the nurse left some food she did find on his bedside cabinet and returned 10 minutes later.

The man was still not in his room, and the nurse assumed that he was in the toilet, as it was occupied.

Health NZ said the nurse’s assumption meant she didn’t recognise the need to sight the man, and his missing status was not triggered.

Health NZ told the HDC the nurse understood the assumption she made was an error in judgment.

The nurse checked his room again at 10pm and, as he was still not there, she tried to call his wife to ask whether he had a mobile phone, but she didn’t answer the call.

The nurse then tried to find the man outside of the CCU, and downstairs.

Then she informed the nurse co-ordinator and rang hospital security, but the exact timing of this is unknown.

Waikato Hospital CCTV footage showed the man standing in front of a vending machine at 10.27pm.

His wife told the HDC he would have had to move from one end of the ward, past the nurses’ station, past the reception area to the doorway, where he would have had to press the hand-activated button to exit.

CCTV footage also showed that 11 people walked past him, seven of whom appeared to be staff, however, nobody appeared to check on him.

At the end of the CCU, there were double fire doors that did not sound alarms on opening.

At 11.01pm, the man was found unconscious on the stairwell past the fire doors.

A cardiac arrest call was put out, and CPR was started, and his blood glucose level was noted to be 1.8mmol/L.

He died at 11.22pm.

The man’s wife was concerned he was missing from the ward for 55 minutes before a search was undertaken, and “it was not until 76 minutes after he left CCU3 that he was found”.

‘Severe departure’ from expected level of care
Independent advice was given to the HDC by registered nurse Marion Picken.

Picken noted the standard of cardiac management was acceptable, but identified other departures from the accepted standards of care.

The nursing admission assessment and documentation by ED nurses was a “moderate to severe departure”.

The standard of diabetic management over the course of his admission was also a “moderate to severe departure”.

And the appropriateness of overall management of the man, in light of his age, frailty, cognitive impairment, and consideration of delirium, was a “severe departure”.

Aged Care Commissioner Carolyn Cooper expressed her sincere condolences to his family.

Aged Care Commissioner Carolyn Cooper.

“Mrs A was closely involved in her husband’s care, and his sudden death has been traumatic for her and the family,” Cooper said.

Having reviewed the evidence, she found Health NZ “failed to provide Mr A with a reasonable standard of care in accordance with Right 4(1) of the Code of Health and Disability Services Consumers’ Rights (the Code)”.

Cooper was critical of the care provided by the ED, and noted there was minimal documentation of the care the man received, and limited evidence of a nursing assessment, particularly with respect to his diabetes.

She was particularly critical of the lack of blood glucose level monitoring, and that this led to his wife checking and administering insulin herself.

Cooper said that while the afternoon nurse recognised when the man became hypoglycaemic, and sourced food, she did not check if he had eaten it, nor did she recheck his blood glucose levels afterwards.

“I am concerned that she did not check Mr A’s whereabouts, and she delayed her escalation to the nurse co-ordinator. In the context of Mr A’s underlying cognitive impairment and hypoglycaemia, this was crucial,” Cooper said.

While there had been a lack of critical thinking by the nurse, there were also failures by Health NZ, including inadequate food in the unit, and inadequate systems to alert staff when patients left the unit, given the man was able to walk past seven staff while outside the unit, with none of them stopping to assist him.

Health NZ made changes after the event, including that all doors in and out of the unit are now more secure, with swipe-card access to get in, and a door-release button on a side wall to get out of the unit.

The door can be locked from a central point if required, and there is signage at exits to remind patients and family to let a nurse know when they are leaving and where they are going.

The fire door in the unit is now alarmed to alert staff if the door has been opened.

The fridges in all the coronary care units are checked daily to ensure sufficient stock of snacks for patients with diabetes and staff ensure patients with low blood glucose levels receive their food in a timely manner and, where this does not occur, an escalation process is initiated.

There have also been improvements made to the way patients with dementia are managed, including where in the unit they are placed.

The ED nursing documentation is subject to weekly audits.

Cooper recommended Health NZ Waikato provided a letter of apology to the man’s family, provide education sessions on the expectations for nursing documentation within the ED, and provide the HDC with evidence of the last three months of the weekly documentation audits undertaken in the emergency department.

It was also recommended Health NZ Waikato undertake a random audit of 15 patients with diabetes who presented to a coronary care unit over the last 12 months to check whether the diabetes management was adequate, and send the results to the HDC.

Hannah Bartlett is a Tauranga-based Open Justice reporter at NZME. She previously covered court and local government for the Nelson Mail, and before that was a radio reporter at Newstalk ZB.