Wellington Hospital doctors have faced criticism over the death of an elderly Island Bay woman, whose lung was accidentally pierced four years ago during a procedure to drain fluid from her chest.
Coroner Ian Smith said in his written decision, released today, that Judith Seymour Sheehan, 76, died on April 3, 2010, after her right lung was perforated during a registrar's attempt to drain fluid from around her lungs, causing internal haemorrhaging and cardiac arrest.
Smith's report highlighted criticisms by an independent Auckland medical expert over the hospital's failure to use ultrasound to mark the level of fluid in Sheehan's lungs before inserting a needle to aspirate it.
Auckland consultant/geriatrician Dr David Spriggs also noted it ''was not standard procedure'' to drain excess fluid from someone's pleural cavity, the fluid-filled space between the lungs and chest wall, without a significant amount of fluid visible on an erect chest x-ray.
Two chest x-rays of Sheehan during her short hospital stay showed very little fluid in her chest cavity.
The fact the 3cm needle pierced her lung by a centimetre when her chest wall was 2cm thick suggested there was no significant fluid where it was inserted and it was possible the needle entered above the fluid level.
Consultant physician Dr Elaine Barrington-Ward failed to recall, accept or review the chest x-ray or order an ultrasound before asking for aspiration, which was ''a significant departure from accepted practice'', Spriggs said.
The registrar, Dr Ilamaram Kumarasamy, failed to check those images and relied on his consultant's advice, Spriggs said.
''It came as a surprise to Dr Spriggs that the (Capital and Coast District Health Board's) internal review did not acknowledge this oversight,'' the coroner said.
She was on medications that increased her risk of bleeding, including blood thinning drugs, but coagulation studies prior to the procedure found nothing of concern.
Smith said Sheehan was admitted to Wellington Hospital on April 1, 2010 for increasing shortness of breath from her congestive heart failure.Barrington-Ward examined her the next day and diagnosed pulmonary oedema, starting her on diuretic medications.
However, she remained ''significantly short of breath'' on April 3 and a CT scan detected a large amount of fluid around her right lung.
The consultant decided the best treatment was to aspirate the fluid and on-call registrars agreed to carry out the procedure.
After Kumarasam inserted the needle, Sheehan coughed up blood, so an ultrasound was done to check the fluid's location.
Next, he inserted a narrow chest drain, which caused her chest pain so it was removed and a chest x-ray was done, which showed the fluid had either moved or a possible bleed around her lungs.
Sheehan became increasingly breathless so Barrington-Ward was notified, who ordered another chest x-ray, which confirmed a large bleed in her chest. She was transferred to ICU, where she had a large bore chest drain inserted, but deteriorated and died that day.
The district health board's internal review found that attempting the pleural effusion was reasonable and had taken into account Sheehan's history, medications and condition, Smith said.
It made various recommendations, including that ultrasound should always be performed before pleural aspiration to mark the level of fluid and registrar training about such procedures was boosted.
Its deputy chief medical officer, Dr Grant Pidgeon, said in a written statement yesterday it had apologised to Sheehan's family and had made changes to registrar training plus over the use of ultrasounds as a result of her death.
''CCDHB can confirm that the Capital & Coast fully accepts its responsibility for providing safe health care and we take the coroner's findings and recommendations seriously. We are always looking to improve and strengthen our services with a culture of patient safety, good communication and continuous quality improvement.
''Any incident which involves a patient suffering harm or death while in our care is one event too many.''
- The Dominion Post
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