DHB's 'serious and significant failings'

A coroner has found serious failings at the Bay of Plenty District Health Board that contributed to two deaths.

Coroner Wallace Bain today released his findings into the deaths of Ian Donald McLeod, 66, and Marlene Joan Strongman, 78, in 2012 and 2010 respectively.

Both had been in the care of the board, and the coroner said the poor level of care they received "contributed significantly to the deaths".

"Both deaths also establish there were significant deficiencies in the manner in which the Bay of Plenty District Health Board communicated with the families," he said.

McLeod died of acute pneumonia and chest infection at the Waipuna Hospice in October 2012.

He had been receiving treatment for non-Hodgkin's lymphoma since 2005 and rectal cancer from 2011.

He had a portacath inserted in 2011 at Tauranga Hospital that was used to infuse drugs and fluids during chemotherapy.

At some point before July 4, 2012, X-rays showed the portacath had shifted into a dangerous position where the chemotherapy drug was being administered directly into his lung.

The coroner said the significance of this shift was not appreciated by the radiologist or by the clinicians treating McLeod.

"That disconnect between the clinical picture and the radiology imaging led, in the court's view, to the catastrophic delivery of chemotherapy into his trachea," he said.

By September 21, 2012, McLeod had been coughing up blood for weeks.

He had another dramatic coughing fit that night and lost consciousnesses.

He was cared for at home before being transferred to the hospice, where he died on October 1, 2012.

Tauranga Hospital failed in five areas, including a failing to appreciate the severity of McLeod's condition on September 19, 2012, and a lack of communication between emergency radiology and oncology departments, the coroner said.

The family asked the hospital and health board to make changes after his death, but the hospital failed to acknowledge the failings in his care and change its protocols, he said.

Strongman died of a hypoxic brain injury secondary to aspiration pneumonia on June 23, 2010, at Tauranga Hospital, the coroner found.

She was admitted a week before with a cough, vomiting, dehydration, irregular pulse and a 5-centimetre lump in her groin after referral by her GP.

A junior registrar diagnosed her with an abdominal malignancy, but this was not reviewed for 27 hours while she continued to vomit and her breathing deteriorated significantly.

She rapidly deteriorated and died from a severe brain injury suffered during a cardiac arrest, the coroner said.

"If there had been appropriate interventions, then [she] would still be alive," he said.

Her care had already been the subject of a damning Health and Disability Commissioner (HDC) report and was also the subject of an ACC claim.

Poor record-keeping, inconsistent and flawed clinical handover processes by medical staff involved and a failure to diagnose an abdominal hernia with bowel obstruction resulted in breaches of the Code of Health and Disability Services Consumers' Rights, the report said.

Strongman's daughter, Queenstown lawyer Jane Taylor, said in her submission to the inquest that the attitude and communication of the health board after her mother's death had been "beyond comprehension".

She said the board never undertook an independent review of her mother's death, and it was up to her family to do so.

"We are also very concerned that the DHB failed to carry out an independent review of Mum's care – rather, a physician employed by the hospital was instructed to do so," she said.

"The internal report ... was lightweight at best and contained many factual inaccuracies."

The coroner agreed with the HDC findings.

He endorsed the HDC recommendations and made further recommendations, including the need for the health board to urgently address the significant deficiencies in the manner in which it had communicated with the families.

"Sadly, this inquest again established that the family of Mrs Strongman were appalled at the way they had been treated by the BOPDHB and their lack of appropriate response to the HDC recommendations," the coroner said.

"They felt the HDC recommendations had not been implemented and they were concerned at the tardiness in response to the recommendations."

The board acknowledged its deficiencies at the inquests and said it had taken significant remedial action to try to ensure such incidents did not happen again.