A man who was taken to hospital with fractured ribs and bruised lungs was left a paraplegic after a chest drain was inserted incorrectly.
The man had been admitted to Auckland City Hospital following a car crash in 2022 where, four days into his stay, he was assessed as having a build-up of fluid between the tissue lining his lungs and chest and would require surgery.
Health NZ’s Chest Drain Management policy stated, unless in an emergency, all chest drains for fluid aspiration should be guided by real-time radiology imaging.
However, said the request for real-time radiology imaging was not accommodated by the Interventional Radiology team, for reasons Health NZ were unable to determine, according to a Health and Disability Commission (HDC) report released on Monday.
A chest ultrasound was scheduled to indicate where the drain should be inserted, but the patient was in pain and could not be moved for the scan, the report said.
A different technique was used, that was deemed to be less painful and invasive.
Two attempts were made by a registrar to insert the chest drain using the different technique, before other doctors took over.
Dark, old-looking blood was drawn from the patient, and he began to sweat. His condition deteriorated and a code red was issued, the report said.
“The code red response was described in the [Serious Adverse Event Review] as chaotic, noisy, and without a clear code leader or any detailed communication or indication of the volume of blood that [the patient] had lost.”
“Sadly, as a result of hypovolemic shock and cardiac arrest, [the patient] developed ischaemic bowel and spinal cord injury, which resulted in paraplegia from the level of the T9 vertebrae, and suspected mild hypoxic brain injury,” the report said.
The investigation by the HDC revealed the chest drain was inserted incorrectly, which led to a hepatic vein injury and massive bleeding.
Other issues had arisen from the resuscitation efforts, it said.
“…the procedure room was cluttered, and there was a lack of code leader to determine when a code red and subsequent code blue was required.”
“In addition, the communication among the staff present was poor, and the equipment required for a code red and/or code blue was not readily available as it should have been.”
Deputy Health and Disability Commissioner Dr Vanessa Caldwell recommended Health NZ’s chest drain policy be updated, encompassing environmental safety, training and education requirements, as well as technical guidelines, and oversight of relationships.
She wanted a copy of the updated policy within six months of the report.
Caldwell also recommended the senior clinician who made the decision to perform the procedure without real-time radiology, write an apology to the patient.
rnz.co.nz
