Three avoidable deaths on list

23:00, Nov 21 2012

A grieving Dannevirke family is reliving the trauma of the death of a four-year-old girl with the annual release of a list of hospital mistakes.

Stevie McCutcheon had a rare and incurable illness called Batten disease that robbed her of the ability to walk, talk, eat and drink, and she depended on a feeding tube inserted directly into her stomach for nutrition.

She died at Palmerston North Hospital last year after her feeding tube became dislodged and was put back incorrectly.

The mistake meant food was going into her abdominal cavity, not her stomach. She suffered poisoning or "overwhelming sepsis" and died in July.

Mid-Central Health will not comment on individual cases reported as part of the serious and sentinel events analysis, which was released by the Health Quality and Safety Commission yesterday without any identifying details.

But Stevie's mum Erin said she had been warned the case would be among the events reported.


Since her daughter's death she said there had been communications with hospital staff, and the issues had been resolved "as well as they could be".

She was not taking the complaints she brought to the Manawatu Standard last year any further, and did not want to talk publicly anymore.

The death was reviewed by Mid-Central Health, which found insufficient knowledge and inadequate guidelines for the acute management of a dislodged feeding tube, along with failure to recognise a potentially serious condition, had been "causal factors".

It recommended a process be set up for the management of children being fed through an abdominal tube. It also recommended education for staff and improving ways to help assess the pain and distress of children who had trouble communicating.

The tragedy was one of three potentially avoidable deaths reported in Mid-Central District Health Board's summary of 15 serious and sentinel events in the year to the end of June.

Another patient died three days after a fall that caused a brain bleed.

The third death happened at home and was discovered when a nurse came to change the dressing on a surgical wound where an abscess had been treated.

In line with national trends, falls were the most common incident, accounting for nine of the 15 events, most often when patients got out of bed to go to the toilet.

One patient broke a wrist and another, a knee, in falls after refusing to use a walker. Another patient who was not assessed at risk of falling fell in the bathroom and broke a wrist.

Other falls happened when a visitor tried to help, and two restless patients climbed over bed rails.

The number of falls was down from 12 last year, but up on seven the year before.

Mid-Central Health has a Falls Action Group providing more education for staff, and encouraging increased use of falls alarms systems, and reviewing the use of bed rails for patients at risk of falls.

Other events included the misdiagnosis of a broken hip, a swab left inside a surgical patient, an ankle dislocation when a nurse shifted a plaster backslab on the lower leg, and delay in getting a pregnant woman from a rural area, two weeks overdue with a cord prolapse, to hospital.

There were no mistakes with medications.

Mid-Central reported 22 events last year, and 18 the year before.

Manawatu Standard