Doctors at a private hospital in Gisborne took too long to transfer a woman to higher level care when she started deteriorating after weight loss surgery, a coroner says.
Janet Milner, 50, died in Waikato Hospital on 18 July, 2021, after bariatric surgery at the private Chelsea Hospital in Gisborne.
In his report, Coroner Bruce Hesketh also found Milner had a type of mechanical heart valve that was recorded incorrectly by her GP to her surgeon and anaesthetist, and this affected her post-operative care.
He found Milner was not an appropriate candidate for bariatric surgery on the date she had the surgery due to this error, and given her significant existing medical conditions, an extremely high Body Mass Index (BMI), and mixed cardiac disease.
Milner had a laparoscopic sleeve gastrectomy stomach removal at the private hospital on July 14, 2021. Two days after her surgery she experienced shortness of breath, a cough and chest pain which were symptoms of cardiogenic and septic shock.
From Chelsea Hospital she was transferred to the Intensive Care Unit (ICU) at Gisborne public hospital, but after her condition deteriorated further, she needed to be transferred to the ICU at Waikato Hospital, where she died on July 18.
‘Professional duty’
Milner had asked her GP Dr Mark Devcich about being considered for weight loss surgery in late 2020. She sought a discussion with a surgeon in Hastings who recommended Dr Peter Stiven in Gisborne for the procedure.
In his report, Hesketh found that Devcich had incorrectly referred to Milner’s mechanical heart valve as an aortic, rather than a mitral valve replacement. There was a record of Milner having a mitral valve replacement from a consultation with a Christchurch cardiologist in 2018, but this did not make it into the 2021 referral notes.
He accepted Milner herself was mistaken about the type of her mechanical heart valve and told a number of doctors and specialists it was the wrong type.
While he had sympathy with the GP, he found it was his “professional duty” to record all relevant medical information in a referral letter to a specialist surgeon.
“In this case, that should have included a more detailed medical history of Ms Milner than was recorded, taking into account the nature of the surgery being considered,” Hesketh said.
He said the patient’s post-operative care was not prepared for her true medical condition because of this error, and the surgeon and anaethetist Dr Christian Hirling would have planned her treatment recovery differently had they known of the correct mechanical heart valve.
“As Mr Stiven has said himself, had he been aware it was a mitral valve it would have been a game changer.”
Move to higher level care took ‘too long’
Hesketh found that it took too long for staff at the private Chelsea Hospital to transfer Milner to a higher level of care at Gisborne Public Hospital, as she was deteriorating after her surgery.
While the surgery itself had no errors and was uneventful, two days after the procedure Milner had developed low oxygen levels, was coughing, had discoloured mucus, and her blood pressure was low.
Hesketh found she should have been transferred in the late afternoon or evening of 16 July, rather than by 11.25 pm, which was when the ambulance arrived at Chelsea Hospital.
“Ms Milner should have been transferred to Gisborne Public Hospital sooner. The decision to move her to a higher level of care took too long.”
Staff on site had requested a non-urgent ambulance transfer at 10.30 pm, and the coroner found there were differing accounts about the direction given at the time – with Stiven saying he had directed an urgent transfer, and the registered nurse saying there was no instruction for an urgent transfer.
Hesketh also criticised a lack of notes around Milner’s deterioration, saying that no proper written record of early warning scores were kept by nursing staff, and Stiven’s records to “continue with cares” in the afternoon of July 16, were not detailed enough.
“The record of Ms Milner’s post-operative care throughout the day and into the evening of 16 July 2021 was sub-optimal.”
A spokesperson for Chelsea Hospital said the hospital expresses its deepest sympathies to to the whānau and friends of Milner.
“We have taken multiple steps to improve our service delivery since this event, including strengthening our admission processes to ensure that surgery in our hospital is as safe as possible.”
Coroner’s recommendations
GPs preparing referral letters to a surgeon or other medical specialist should ensure they thoroughly review their patient’s notes and include as much relevant information about their patient’s past and present medical history relevant to the specialist treatment.
Chelsea Hospital should remind staff, and if required provide better training, around the recording of early warning scores so that specialists have the clearest picture of a patient’s treatment and recovery.
Surgeons and other specialists should record all their advice, directions and attendances into the patient’s notes so there are proper records of treatment.
By Ellen O’Dwyer for rnz.co.nz
