A woman suffered a brain injury and permanent damage to her memory after being given too many opioids on a busy night at Auckland’s Middlemore Hospital.
The Health and Disability Commissioner has criticised Health New Zealand Counties Manukau, saying it had a responsibility to ensure its ward had enough staff, and that it did not have adequate protocols or documentation in place during the incident in 2021.
The 46-year-old woman was found unresponsive and not breathing properly in a ward shortly after midnight on her second night in hospital.
She was given oxygen and overdose-fighting medication but had already suffered a brain injury from lack of oxygen, likely connected to the opioid use.
The commission’s report said she had been given multiple different types of pain medication – some long term, some short acting, as well as the normal sedatives she was taking.
She had a complex medical history including post-traumatic stress disorder, anxiety, paranoia, obstructive sleep apnoea and had previously suffered from chronic pain disorder
The woman had turned up to Middlemore’s emergency department on the evening of March 4 with abdominal and back pain that was suspected to be gastroenteritis, the commission’s report said.
She was given the opioid fentanyl intravenously, as well as panadol but continued to experience a lot of pain, and was given oxycodone as well as her regular medicines, some of which had sedating effects.
Throughout her stay she repeatedly told staff she was in a lot of pain.
At one point a junior doctor said it was “out of proportion” to the clinical findings.
When she was transferred to ward, she was supposed to be monitored every 30 minutes because of all the medication – but that level of monitoring was not documented.
Health NZ told the commission its ward was very busy and “staffing was ‘stretched’,” with junior workforce caring for patients.
It said in hindsight it should have considered limiting admissions or bringing more staff in.
The commissioner noted that the opioids were given in their recommended doses, but that the woman should have been monitored more closely because of her sleep apnoea and prescription medicines.
There should also have been better protocols, particularly to escalate the woman’s case when it appeared she was not responding to pain medication – even if she was still in the normal dose range
“I am critical that despite Ms B receiving multiple doses of opioids over 24 hours, her pain score was documented only five times, particularly given that it was recognised that the requirement for pain relief was out of proportion to the symptoms, and that Ms B continued to experience pain even when the maximum doses of opioid medication had been given,” the commissioner said.
“In addition, I am concerned that Ms B’s vital signs were not recorded when she was on the ward.”
But she noted that the hospital has made several changes since then, including improving its reporting and monitoring documentation, drawing up written advice and a path for staff to follow if a patient presented in similar circumstances.
In a statement today, Health NZ Counties Manukau acting chief medical officer Geoff Green said it accepted the commission’s findings and had sincerely apologised to the woman and her whānau.
“We take the safety and well-being of every person in our care extremely seriously, and have since made a number of changes to prevent this from happening again in future,” he said.
“These include updating co-prescribing advice and alerts, as well as updating the opioid protocol for adults.”
rnz.co.nz
