Alert 'buried' in notes led to fatal mistake

16:00, Dec 11 2012
Coroner David Crerar.

An internal incident report has found several issues in Dunedin Hospital procedures led to the accidental death of an Alexandra woman last year.

Anne Eleanor Holdom, 76, died on June 20 last year as a result of her injuries after a nurse at the hospital attempted to reinsert a naso-gastric tube after Mrs Holdom pulled it out.

Otago Southland coroner David Crerar's formal findings into her death, released on October 29, said that on May 1 last year Mrs Holdom was admitted to the neurosurgery unit of the hospital after going to her doctor in Alexandra suffering from worsening visual problems.

An MRI scan showed she had a large pituitary tumour.

Mrs Holdom underwent two endoscopic operations to reduce the tumour and was discharged from hospital on May 16 but was readmitted on May 30 and needed to have a cerebral spinal fluid leak repaired and drained on June 8.

It was decided by the clinical team that Mrs Holdom would benefit from a naso-gastric tube to supply her with nutrition and medication which was inserted on June 17.


However, on June 19, despite Mrs Holdom's wrist being restrained, she was able to pull the tube out.

A nurse attempted to reinsert the tube but immediately noticed blood and fluid coming out of Mrs Holdom's nose.

A CT scan showed on reinsertion the tube had been passed intracranially, through a surgical defect, into the mid brain.

It was deemed a non-survivable injury and she died as a result.

A review of care was conducted by the hospital, which "identified a number of issues" including concerns expressed by staff about the complexity, volume and difficulty to access policy and procedure documentation.

There was a clear policy on the insertion of naso-gastric tubes stating they should not be placed or replaced in patients who had undergone a "transphenoidal hypophysectomy" as Mrs Holdom did.

"It is observed that such policy is ‘buried' in other documentation".

The report also found case notes stated the tube should have been reinserted only under direct supervision.

In recommendations the panel that completed the report proposed reinstituting a problem list on the top of each patient file and flagging items of critical importance and placing them in a prominent place on the patient record.

In his findings, Mr Crerar said "there has been no attempt to cover up the incident and the hospital inquiry has focused, as a coroner is required to focus, on both identifying what occurred and attempting to create a situation where the circumstances will not recur."

He recommended that the Southern District Health Board continue with its development protocols to avoid the recurrence of circumstances which led to the death of Mrs Holdom.

"I see the issue, in relation to the fact that critical flags within patient notes being overlooked or buried, as being so important that the lessons learned from the death of Anne Holdom be appropriately drawn to public attention by the SDHB," he said.

"The board should report on the issues identified at a national level."

Mr Crerar said the death was accidental and the hospital had made an apology.

The Southland Times