Families of patients whose deaths were caused by a health board's failures are relieved a coroner has highlighted their concerns and hope the board will change its attitude.
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 patients had been in the care of the Bay of Plenty District Health Board, and the coroner said the poor level of care they received "contributed significantly to the deaths".
McLeod died of acute pneumonia and chest infection at the Waipuna Hospice in October 2012 after years of being treated for cancer.
A portacath inserted in 2011 at Tauranga Hospital used to infuse drugs and fluids during chemotherapy shifted into a dangerous position, at some point before July 4, 2012.
The coroner said the significance of this was not picked up by the radiologist or the clinicians treating McLeod.
By September 21, 2012, he had been coughing up blood for weeks. He died on October 1, 2012.
His son, Scott McLeod, said the family was disappointed to have go to the coroner, but was grateful for the findings.
He said the health board made no effort to be part of the process.
“I’m hoping the local DHB will take on the recommendations, but I’m also hoping it’ll change the way it deals with families.”
The coroner said 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.
As McLeod was ailing, he spoke with his family about how to prevent such errors from happening again.
“He was an engineer,” his son said, “He was trying to think of how to stop it for the next bugger. We wrote [his recommendations] down, took them to the hospital, where they were ignored. So, we took them to the coroner, where they’ve now been implemented nationally.”
He said after hearing how Strongman’s family also suffered, it was evident the health board needed to change the way it deals with families. “The approach the current [board] is taking is so wrong. It makes you feel like a hindrance.”
Strongman died of a severe brain injury suffered during cardiac arrest on June 23, 2010, at Tauranga Hospital, the coroner found. When she was admitted a week earlier, she had been misdiagnosed by a junior registrar at the hospital and concerns about her condition were not passed on to her consultant.
"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.
Strongman's daughter, Queenstown lawyer Jane Taylor, said the family still found it hard to accept “this completely avoidable tragedy could have happened - and that it happened in a hospital environment”.
“It is in the interests of all residents of the Bay of Plenty that the BOPDHB accept full responsibility and be held to account for its appalling omissions in order to restore public trust and confidence in the medical services provided by this hospital, and the public health system generally.”
She said there needed to be “radical improvement in professional attitude by the hospital’s leadership and medical staff”.
She found it “very concerning” the board never undertook an independent review of her mother's death, and it was up to her family, whom the board treated as “the enemy”, to do so.
The coroner agreed with the HDC findings, 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.
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.
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