Woman with sepsis deteriorates during 13-hour wait for hospital transfer

A woman in a rural area with sepsis from a burn was told she could not be transferred to a main hospital because staff there did not think her condition was bad enough, and no beds were available.

The 67-year-old waited 13 hours at a rural hospital where staff urgently tried to arrange the transfer, during which her condition deteriorated.

She was eventually flown to Dunedin Hospital by helicopter, where she was diagnosed with necrotising fasciitis, a fast-spreading and potentially fatal bacterial soft tissue infection.

She died eight months later, in April 2024, after prolonged hospitalisation and difficult rehabilitation.

The case was one of two involving failures at Dunedin Hospital, of which the Health and Disability Commissioner has been highly critical in decisions released this week.

In the second, a man who injured his elbow in a fall at home in March 2021 had his leg amputated in hospital five days later.

However, hours after having his lower leg removed above the knee, the man, who had complex health challenges, died.

The HDC found that individual staff carried some responsibility, but overall Health NZ failed to ensure timely assessment and diagnosis.

Health NZ said it accepted the findings and recommendations in each case and reiterated how sorry it was for the failures.

Health NZ Southern chief medical officer Dr Rebecca Brushwood told NZME their aim was always to provide excellent healthcare. They deeply regretted that in the case involving the man whose leg was amputated, it did not meet those high standards.

“We would like to reiterate our sincere condolences to the patient’s family for the failures outlined in the report regarding timely assessment and diagnosis of the patient’s vascular condition,” Brushwood said.

She said they had since taken significant steps to implement the commissioner’s recommendations and would continue to provide progress updates.

Several changes had been made to improve communication between clinicians regarding a patient’s care plan and escalation pathways.

‘Road blocks’ prevented timely transfer

Regarding the delayed transfer, Health and Disability Commissioner Morag McDowell criticised the barriers that prevented the woman from getting the help sought by her rural hospital.

McDowell said it promptly recognised the severity of the patient’s condition and treatment needs, appropriately requested transfer, and was met with “systemic roadblocks” that increased the risk of harm to the woman.

On the afternoon of August 4, 2023, the woman arrived at her rural hospital’s emergency department with a burn on the top of her hand from three or four days prior.

She had symptoms including vomiting, confusion, and an elevated breathing and heart rate.

She was given fluids and antibiotics on the way in by ambulance.

The sole doctor on shift noted from observations and tests that she had sepsis, possibly because of hand cellulitis (a common bacterial infection of the skin and tissues beneath the skin) as well as hyperglycaemia (abnormally high blood glucose) secondary to infection.

Health and Disability Commissioner Morag McDowell has referred Health NZ to the Director of Proceedings over the delayed transfer to decide on any further action.

The doctor sought more blood tests, including cultures, a urine test, X-rays of the woman’s chest and hand, and a Covid-19 test.

The doctor was concerned she was “significantly unwell” and likely needed care beyond what the rural hospital could provide.

The doctor tried to arrange a transfer to Dunedin Hospital, knowing the road transfer service to Dunedin ended at 7pm.

At the time, the process required the rural hospital clinicians to find an “accepting specialty” at Dunedin Hospital.

The rural doctor asked orthopaedics, plastics, and general medicine to accept the patient, but each declined.

Orthopaedics told the doctor to “talk to plastics”, which reviewed photos and did not think the infection was sepsis.

As a last attempt, the doctor called the Dunedin Hospital general medical service, but the registrar declined transfer because the hospital had no inpatient beds and an ED wait time of 16 hours.

Health NZ said general medicine did not decline patients based on bed occupancy, and records showed 45 beds were available at the time.

The rural doctor handed over to the evening doctor, who was briefed on the situation.

The woman was monitored, given more antibiotics, then admitted to the acute observation unit.

At 8pm she was examined and later that night given more antibiotics.

By 1am the next day, her blood pressure remained worryingly low. At 3am the doctor tried phoning Dunedin Hospital but got no answer.

An hour later the woman’s blood pressure dropped further. She was administered a treatment designed to maintain adequate blood flow to her vital organs while the doctor tried to arrange transfer to Dunedin.

At 6am, the general medicine service accepted the woman for helicopter transfer.

Dunedin has been vocal in recent years about its stretched healthcare services. In 2024, an estimated 35,000 people marched against the Government's proposed hospital cuts in Dunedin. Photo / Ben Tomsett

It was dispatched just before 7am and arrived at hospital two hours later, when the woman was diagnosed with necrotising fasciitis. She underwent extensive successive surgeries and prolonged complex care and rehabilitation.

She was later moved to a residential care facility, where she died in April 2024.

Health NZ said the lack of an escalation pathway with clear criteria for transfer from a rural hospital to a higher level of care, regardless of diagnosis, was the underlying cause of this issue.

‘Serious, systemic deficiencies’

Commissioner McDowell has referred Health NZ to the Director of Proceedings to decide on any further action.

She said there were “serious systemic deficiencies” in what happened, which in her view fell significantly below the appropriate standard.

“I consider that there is public interest in further holding Health NZ to account for these serious deficiencies, and in maintaining, upholding, and enforcing an appropriate standard for timely and safe escalation of care for rural hospital populations.”

Brushwood said, on behalf of Health NZ Southern, that it had already implemented significant changes to strengthen the relationship and communication between Dunedin Hospital and rural healthcare facilities on escalation of care.

They were continuing to work through the recommendations identified by the commissioner.

“We would like to reiterate our sincere apology to the patient’s family for our failings in communication and coordination between services, and the distress this caused,” Brushwood said.

Each incident happened under the previous Labour Government, which at the time was focused on containing and managing the Covid pandemic.

Labour Health spokesperson Dr Ayesha Verrall told NZME her thoughts were with the families of both patients who had lost people they loved, and who had waited years for answers.

“I hope these reports give them some of those answers.”

Verrall said the reports showed failures in how the system worked, and those failures need to be fixed regardless of who was in government.

She said, regarding Dunedin Hospital, the commissioner’s findings concerned systems that depended on having enough staff to run them.

Health Minister Simeon Brown and Labour health spokesperson Ayesha Verrall in the RNZ studio during a Labour and National health debate. Photo / RNZ

Verrall said senior doctors and nurses in the south had been clear they were stretched and the National Government’s hiring freeze and pressure to cut costs made it harder to fix the problems identified in the HDC reports.

“Labour will end the hiring freeze this government has placed on our health system,” Verrall said.

Health Minister Simeon Brown and Health NZ said earlier there was no blanket hiring freeze, stating recruitment continued based on service needs and patient safety.

On failings at Dunedin Hospital, the minister’s office deferred to Health NZ’s statement to NZME.

National candidate for Dunedin Kristine Asuncion told NZME the party expected all Dunedin patients to have access to timely, quality healthcare.

Tracy Neal is a Nelson-based Open Justice reporter at NZME. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.