Fatal medical mishap repeated

NICOLE MATHEWSON
Last updated 16:00 28/08/2014
Keith Nelson
RICHARD COSGROVE/ Fairfax NZ

NOT AGAIN: Keith Nelson hopes for answers about his wife Tracey's death.

Tracey-Jane Havill-Nelson
MUCH-LOVED: Tracey-Jane Havill-Nelson died aged 52.

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A Christchurch couple are wondering how a mistake that killed their young son was able to happen to another family.

Julie and Pete Wright lost their 2-year-old son Jacob in 2007 while he was undergoing treatment in Christchurch Hospital.

A peripherally inserted central catheter (or PICC line) inserted into the toddler's body had shifted, piercing his heart and causing a fatal build-up of fluid.

The couple were surprised to learn the same mistake killed 52-year-old Tracey-Jane Havill-Nelson five years later.

Havill-Nelson died in Christchurch Hospital on June 23, 2012, while she was being treated for malnutrition and dehydration following bariatric surgery.

Keith Nelson said his wife's death "shouldn't have happened" and he wanted to make sure the same mistake did not happen to anyone else.

The Wright's had wanted the same thing when Christchurch Hospital carried out an investigation into their son's death.

"We thought it wouldn't be happening to someone else," Julie Wright said.

A coroner's inquest into Havill-Nelson's inquest today sounded "very familiar" to the one held into their son's death in 2009.

The couple attended today's inquest at Christchurch District Court to find out how the same mistake could have happened to someone else.

"I'd love for it never to happen again," Julie Wright said.

Coroner Richard McElrea today heard that an investigation by the Canterbury District Health Board into Havill-Nelson's death had made nine recommendations for staff.

The recommendations included creating a governance group to provide clinical leadership, management support and clear lines of accountability and reporting in regards to central venous access devices.

Dr Hamish Gray, who chaired the governance group, said all of the recommendations had been implemented or "continued to be implemented".

"I'd also like to pass on my condolences to Mr Nelson and his family for their loss," he said.

Earlier Dr Grant Coulter told the coroner that it was "extremely rare" for a PICC line to move through the heart and, although he had never heard of it happening, it was a known complication.

PICC lines should be monitored daily to check for movement, but there was evidence that had not happened in Havill-Nelson's case, he said.

"Changes have been made that have improved the monitoring of those lines."

A new type of PICC line that was safer and less likely to slip had also been introduced, while more emphasis had been placed on educating staff about the risks.

CDHB chief executive David Meates said the board had apologised to Nelson for failing to provide appropriate care to his wife, leading to her "unexpected and sudden" death.

"Mrs Nelson's death occurred as a result of a number of failings in our system, which have now been addressed."

Canterbury health board chief executive David Meates said the board had apologised to Nelson for failing to provide appropriate care to his wife, leading to her "unexpected and sudden" death.

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"Mrs Nelson's death occurred as a result of a number of failings in our system, which have now been addressed."

The CDHB would accept all of the coroner's findings and had thoroughly reviewed what went wrong to ensure more robust systems were in place and to prevent something similar happening to someone else, he said. 

- The Press

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