'I have nightmares about how she suffered': Woman dies after giving up waiting for hospital care

Michelle Pillay wrote in her hospital discharge form that she was going home as she had “given up waiting to be seen by a doctor”. 

“It seems I am too complex to be treated at [this] Hospital.” 

Hours later she died of a heart attack. 

The Health and Disability Commission has ordered Health NZ to apologise to her family after staff at Tauranga Hospital failed to recognise she was experiencing a significant life-threatening cardiac event. 

Her partner Roisin Connolly said Pillay was the “most amazing person”. 

She was smart, articulate, sassy, intellectual, fun and funny and “always championed the underdog”. 

Connolly said she took Pillay, who was struggling with chest pain, to Tauranga Hospital in September 2022, believing she was in good hands. 

“It failed in its duty of care and I have nightmares about how she suffered. 

“Michelle asked to leave several times because no one would help her and she believed she was going to die there.” 

Connolly raised her concerns about Pillay’s care with the Nationwide Health & Disability Advocacy Service, which in turn asked the Health and Disability Commissioner to investigate her treatment. 

This week deputy commissioner Vanessa Caldwell acknowledged the hospital’s emergency department was under significant pressure and Pillay’s presentation may have been unusual and challenging. 

“However, I do not consider that this context materially mitigates Health NZ’s responsibility to provide Code-compliant care or demonstrates that the care provided was reasonable in the context of these resource constraints. 

“The most significant failing in this case was the delayed recognition that [Pillay] was experiencing a significant and life-threatening cardiac event.” 

In a decision released this week, Caldwell ruled Health NZ breached the Code of Health and Disability Services Consumers’ Rights for failing to provide Pillay reasonable care. 

She was also critical about Health NZ’s lack of clinical notes, the lack of a management plan and poor communication not only between clinicians but also with Pillay and Connolly. 

Chest pain, vomiting and ‘odd behaviour’ 

Pillay was taken to hospital by ambulance about 1.30pm on September 27, 2022 after developing chest pain, vomiting and urinary incontinence. 

The electrocardiogram (ECG) completed by ambulance officers was described by Hato Hone St John as indicating a normal heart rhythm. 

Her initial physical observations in ED were normal and remained largely normal when repeated, aside from one instance of a slow heart rate at 46 beats per minute and two episodes of elevated blood pressure. 

Pillay was described by her partner as someone who “always championed the underdog”. 

At triage, she was noted to exhibit worsening general body pain, convulsions and “odd behaviour”. 

In her initial ED review, the doctor noted that Pillay was distressed and thrashing on the hospital bed, which made it difficult to carry out tests. 

The overall impression was that she was agitated from an unknown cause, possibly medication withdrawal or a side effect, as she was on several medications and had recently stopped taking some. 

The doctor’s orders included an ECG, the findings of which were sighted but not in Pillay’s clinical notes. 

Health NZ told HDC during the investigation that Pillay’s identification details were not entered into the bedside monitor and, because the initial ECG was not labelled, it was appropriately destroyed. 

Mental health assessment ordered 

The doctor then handed Pillay over to an emergency medicine specialist, who was told the ECG was normal. 

But he found Pillay’s demeanour bizarre, noting that she had poor concentration and was argumentative and combative, so he ordered a mental health review. 

The doctor had written in the clinical notes that the woman had been ‘medically cleared’ and had been referred to the crisis team; however, subsequent ED nursing notes noted she was not medically cleared. 

Connolly said Pillay was complaining of chest pain the entire time at the hospital. 

“Michelle was not seen as a human being in pain who needed urgent help. Her death was painful and degrading. 

“The hospital chose to believe it was all in her head and as a result, did not carry out the essential tests that would have shown she was suffering a cardiac event.” 

The specialist said that the psychiatry service asked him about Pillay’s ECG. He had not sighted the original ECG and could not locate it, so he ordered another at 8.46pm, which was abnormal. 

The ECG was repeated at 9.34pm and was again abnormal. 

He sought the opinion of an emergency medicine colleague and they agreed that the changes visible on the ECG could not be attributed to Pillay’s medications. 

He was then called away to perform several critical procedures on other patients. 

It is unclear what was communicated to the couple about the ECG results or intended next steps and there was no reference in the clinical notes to the 8.46pm and 9.34pm ECGs. 

Woman leaves hospital 

Connolly recalled being told by a nurse that the doctor who reviewed the ECG changed his mind and no longer saw anything of concern and that Pillay might not be seen by a doctor again until the morning. 

She said she was horrified because Pillay had not had anything to eat or drink all day and was getting weaker. They were feeling frustrated and upset, as though they had been ignored all day. 

“The hospital had cleared her and bought us our taxi home,” Connolly said. 

“We felt neglected at the hospital and thought that if she was home she could at least have water and pain relief.” 

Pillay then self-discharged, writing: “I am going home because I am not receiving any treatment here. The nurses are helpful and doing their best but I have given up waiting to be seen by a doctor. 

“I have not eaten or had anything to drink all day. I am type 1 diabetic and complex health needs and it seems I am too complex to be treated at [this] Hospital.” 

Earlier, a troponin test had been ordered, which showed damage to her heart. The hospital tried to contact Pillay but calls went unanswered. 

At home, she remained distressed and became short of breath and was taken to another hospital by ambulance. 

She went into cardiac arrest shortly after arriving at hospital and died at 9.07am on September 28. The cause of her death was determined to be a heart attack. 

Several nursing staff who provided statements to HDC’s investigation commented on the “lack of communication between doctor and nurse, nurse and patient, doctor and patient” and that the management plan for the woman was at times unclear. 

Similarly, the clinical notes show that, at 8.50pm, nursing staff were ‘awaiting plan from [the specialist]’ and at 10.05pm were “unsure of plan”. 

A nurse also stated that about 10pm, she asked an ED doctor if a troponin test was required and recalled being told the ECG was not a concern. 

Health NZ completed an adverse event investigation 10 months after her death and found there was a failure to run multiple diagnoses or consider differential diagnoses for her presentation; troponin was not included in the initial blood work and the meaning of medical clearance was misinterpreted. 

It had since made a number of changes, including integrating a new ECG process. 

The HDC also recommended that Health NZ provide written apologies to the Pillay family and Connolly and update the HDC on the progress of the changes it had made and the effectiveness of the new ECG process. 

Connolly said she was angry the HDC allowed the hospital four years to sort out its failings so that by the time the report was released, the hospital need not face any punitive measures for its failings. 

“It doesn’t feel like there has been any justice for Michelle.” 

Joanne Gibbs, Health NZ interim group director operations Bay of Plenty, said Health NZ accepted the findings and recommendations. 

“We extend our sincere apologies and condolences to [the woman’s] partner, whānau, friends, and community for their loss and the ongoing impact of this event. 

“We remain committed to learning and continuing to improve the care and services we provide.” 

Brianna McIlraith is a Queenstown-based reporter for Open Justice covering courts in the lower South Island. She has been a journalist since 2018 and has had a strong interest in business and financial journalism.