A family has described watching their loved one deteriorate over three days while in hospital, before dying during a transfer, as severely traumatic.

The woman was left with no pain relief for six hours as sepsis took hold, while family members spent an agonising night watching her rapidly decline with no explanation, or doctors in sight.

Now, the Health and Disability Commission (HDC) has found there were several systemic and organisational issues at Wairarapa Hospital which breached the 54-year-old’s rights to reasonable care.

According to today’s HDC report, in August 2020, the woman went to her local GP with rectal bleeding and, after examinations, was diagnosed with haemorrhoids and given topical cream.

Six months later, she reported a flare-up of symptoms and was given another prescription of topical cream.

A referral was made for a private colonoscopy, which occurred a month later, and a tumour was found. Another scan a month later confirmed the colorectal cancer had spread.

In July 2021, a plan was made for her to undergo chemotherapy - however, she required a temporary colostomy bag, or stoma, before the treatment.

The surgery was completed and she began chemo on August 5.

Within days, the woman developed severe abdominal pain and collapsed at home.

A nurse who conducted a house visit told the HDC the woman stabilised; however, this was not noted in her medical file.

Around this time, her cancer care co-ordinator went on leave, and nobody was assigned to fill her role.

What followed was three traumatic days at Wairarapa Hospital as her family watched her slowly deteriorate, and eventually die.

She arrived at the emergency department with abdominal pain, vomiting, and also collapsed.

After tests, the staff suspected chemotherapy‑related sepsis.

She was admitted to the Medical Surgical Ward (MSW) for fluids, antibiotics, and monitoring. However, her condition worsened overnight.

The woman vomited repeatedly, required escalating pain relief, and remained unsettled.

By morning, she was pale, sweaty and blood tests showed clear signs of infection.

A CT scan revealed a large bowel obstruction.

Crucially, it did not show a perforation – a detail that would later become central to the investigation.

“The fact that no bowel perforation was seen at this time is important, as following her death it was identified that Mrs A’s bowel had perforated approximately 21cm from the end of the stoma,” HDC Commissioner Morag McDowell said in her report.

“How and when the perforation occurred is relevant information to assist in determining whether an appropriate standard of care was met.”

Family members said they were traumatised as they watched their mother taken to the high dependency unit. Photo / 123rf

A surgeon drained 1.1 litres of fluid from the colon, which gave her a short-lived reprieve.

Twice, her blood pressure dropped, with her vital signs being in the red zone, meaning urgent escalation of care was required.

Health NZ policy states that every time vital signs are measured, the Early Warning Score (EWS) must be calculated.

However, this was not done in the 15 hours after the second time her blood pressure dropped.

She was given IV fluids, taken off pain relief and placed on a portable monitor for intermittent recording of her vital signs.

However, the details of the last patient were still logged into the monitor.

At some point, a high dependency unit (HDU) staff member noticed the deteriorating vital signs. However, staff could not locate the patient because of the incorrect details.

Despite her charts showing she was in the critical “blue zone”, it was not for another two hours and 20 minutes that an emergency bell was activated by a nurse, in front of family members.

“It is unclear why the [Medical Emergency Team] call was not made earlier than it occurred,” the report said.

With the woman still conscious, she was transferred to the HDU but no one advised the woman or her family what was happening, causing them to panic.

Her family described the scene as traumatic and the HDC agreed, finding the hospital’s communication was “entirely inadequate”.

Blood results soon indicated the woman was in a significantly septic state and an on-call surgeon, Dr D, attempted to decompress the bowel.

He then inserted a chest drain into the stoma, a move the family described as forceful and distressing.

Dr D insisted he used no uncontrolled force. However, the forensic pathologist later concluded the bowel perforation was “most likely” caused by the chest drain, though the HDC did not find Dr D in breach.

“The fact that this attempted aspiration used a rigid catheter and that it was performed after the CT scan, which showed no perforation, the paucity of inflammation and ischemia in the surrounding bowel wall, and the patient’s deterioration thereafter, suggests strongly that this catheterisation was the source of the trauma,” the pathologist said in her report.

A decision was made to transfer the woman to Wellington Hospital but a lack of beds and poor weather meant it was not immediately possible.

Health and Disability Commissioner Morag McDowell. 
Health and Disability Commissioner Morag McDowell.

Overnight, she deteriorated and family members told the HDC that communication from hospital staff was non-existent. They had asked nurses several times through the night where the doctors were.

About 4am, the woman received her first dose of fentanyl.

As the hospital prepared to transfer her to Wellington, the family were not told how serious her condition was.

“A severely traumatic event for us all made worse by the lack of honest communication from everyone,” the report said, referencing the family’s recollection.

The woman suffered a cardiac arrest in transfer and was pronounced dead at 11.29am.

In the report, McDowell said the hospital’s most significant breach was the staff’s failure to comply with the EWS pathway.

She said the delay in care, from when her blood pressure dropped, was a critical point of failure and should have been escalated earlier.

McDowell also noted the assignment of portable monitors showed an inadequate system, and another missed opportunity to recognise her deteriorating health.

She found Health NZ Wairarapa breached its communication policies.

“Health NZ acknowledged that the sudden activation of the emergency bell [following the MET call] was distressing for both Mrs A and her family, who were not advised by the nurse of its imminent activation.”

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McDowell was highly critical of the delay in pain relief and found the hospital breached in relation to the woman’s pain control.

“I am saddened that this would have undoubtedly negatively impacted Mrs A. I concur with the ERR that intravenous analgesia was not utilised well and there was no reason for additional pain relief not being provided to Mrs A at these times.”

Health NZ said it has made changes since the woman’s death, which include a deteriorating patient working group and a patient at risk nurse team.

A number of other guidelines have also been implemented.

“Dr D told HDC that he ‘commiserate[s] deeply with the family for their tragic loss’.

“He stated that there has not been a single week over the past four years in which he has not reflected on this incident and that it was ‘one of the most traumatic cases over a very long surgical career’,” he told the HDC.

The HDC recommended that Health NZ provide a formal apology to the family and provide updates to the watchdog on the implementation of their reviews.

They are also recommended to undertake a random audit to determine the level of compliance was being met.

Health NZ Wairarapa told HDC that it has a profound sense of regret for the incident and expressed its condolences to the woman’s family for their loss.

It also acknowledged the family’s grief was “compounded by the deficiencies in the care that Mrs A received”.

Shannon Pitman is a Whangārei-based reporter for Open Justice covering courts in the Te Tai Tokerau region. She is of Ngāpuhi/ Ngāti Pūkenga descent and has worked in digital media for the past five years. She joined NZME in 2023.