Coroner finds woman who died at Waikato Hospital ‘not subject to any effective form of clinical monitoring around the time she died’

Monday, 2 September 2024

A Coroner’s report into the death of an 84-year-old woman at Waikato Hospital has found her death was preventable and that she was “not subject to any effective form of clinical monitoring around the time she died”.

“I find that Ms Tomelty’s death was, on balance of probabilities, preventable,” said Coroner Ian Telford.

The findings come in the wake of claims from New Zealand Resident Doctors Association (NZRDA) national secretary Dr Deborah Powell that patient safety is at risk at the hospital.

Barbara Tomelty died at Waikato Hospital on February 5 last year, with the cause of death ruled as cardiac arrhythmia.

The report noted the retired 84-year-old died of natural causes, though Coroner Telford also noted “due to the circumstances surrounding Ms Tomelty’s death (which I find may have been preventable), I have made a range of comments and recommendations”.

Tomelty was transported to Waikato Hospital on February 4, 2023, from her aged care facility with worsening chest pain.

“At 4.50pm Ms Tomelty was triaged in the ED by a nurse as Category 3, meaning she should have been seen by a doctor within 30 minutes of arrival,” Coroner Telford said.

“In this case, Ms Tomelty was seen at about three hours and 50 minutes after arrival.”

The report also noted a monitor alarm was activated, “however, this was not detected by the ED staff”.

Coroner Telford said that on the night Tomelty was admitted, the emergency department was “five RNs [registered nurses] short, four sick and one roster gap”.

He said that while the staffing levels were not seen as a contributory factor, “this inquiry has found that the nursing ratio was far lower than recommended”.

“At the time of the critical event, the nurse-to-patient ratio that night was lower than the ratio recommended by the New Zealand Nurses Organisation and the College of Emergency Nurses New Zealand”.

Coroner Telford also found that the time from triage to cardiac arrest totalled eight hours and 20 minutes in the ED.

“This delay in care, known as ‘ED access block’, has been found to adversely impact on all aspects of acute medical system performance,” he said.

“This includes increased patient harm and mortality, increased patient wait times, increased patient hospital length of stay, and increased ambulance turnaround times.”

Coroner Telford’s report also includes responses from Health NZ Waikato, including a November 2020 review that “highlighted the urgent need to address staffing issues to be able to offer trainees a safe and appropriate training environment”.

He also said that while Tomelty’s age would have “lowered her average rate of survival”, “I prefer the court’s experts’ advice in this regard - that there was a ‘reasonable chance … statistically in the order of up to 70% of Ms Tomelty responding to electrical cardioversion if her critical arrhythmia had been detected immediately and similarly treated with cardiac defibrillation”.

“Ms Tomelty ended up in the ED for a long time, awaiting specialist assessment,” Coroner Telford said.

“If she had been assessed sooner, it is likely she would have been admitted to a different clinical area where more suitable monitoring and treatment would have been available.

“I therefore conclude that, although Ms Tomelty was acutely unwell, she was not subject to any effective form of clinical monitoring around the time she died”.

Coroner Telford made a number of recommendations including a review of the ED configuration “with the aim of ensuring patients who are unstable and complex are nursed in clinical areas where they are directly observed by nursing staff”.

He also recommended HNZ Waikato develop and use a care pathway for the triage, assessment and management of chest pain, and that the pathway “established with clarity the level of nursing observation required for patients in this category”.