Health and Disability Commissioner Anthony Hill today released a report finding Nelson Marlborough District Health Board
in breach of the Code of Health and Disability Services Consumers’ Rights for its care of a 65-year-old woman who had
undergone bowel surgery.
Shortly after her surgery, the woman had a high white cell count and started to show signs of postoperative ileus
(obstruction of the bowel). She continued to deteriorate in the days that followed. Four days after her surgery, she was
diagnosed with acute respiratory distress and was transferred to ICU. She died later that day.
Mr Hill found that opportunities were missed to implement appropriate treatment for the woman and escalate her care.
Mr Hill considered that there was a lack of timely investigation into whether the woman’s persistently high white cell
count was caused by infection. He was also concerned about an apparent failure by medical staff to consider the
possibility of inserting a nasogastric tube on the morning that the woman was transferred to ICU.
"Given the woman’s known problems, it appears that inserting a nasogastric tube should have been considered at this time
to treat the issues stemming from her ileus and respiratory distress, and I am concerned that this did not occur," Mr
Hill said.
Mr Hill was also critical about the care the woman received once she was transferred to ICU. He found that a nasogastric
tube should have been inserted prior to starting non-invasive ventilation, that there had been a delay in escalating her
care to the consultant anaesthetist, and that invasive ventilation should have been implemented sooner when it was clear
that the woman was experiencing severe respiratory failure.
In response to recommendations from Mr Hill, the DHB provided a written apology to the woman’s family and reported on
its implementation of new clinical guidance on non-invasive positive pressure ventilation.
The full report for case 17HDC00679 is available on the HDC website.
ENDS