Crucial X-ray unseen

16:00, Mar 22 2014

A man who died in hospital could have been saved had a doctor, overwhelmed by a busy night shift, not forgotten to review an X-ray, a coroner heard last week.

Trevor Bourke, 69, checked himself into North Shore hospital after experiencing ongoing dull chest pain at 11.45pm on May 25, 2013. By 11.30am the next day he was dead from a tear in his aorta.

The senior registrar on the night shift, Dr Aik Haw Tan, failed to review the X-ray that could have led to the diagnosis of the tear, because the hospital had been very busy that evening.

"I most probably would have forgotten. I must have forgotten to review [the X-ray] because of the business of the night. I agree the opportunity for early diagnosis was missed," he told the Coroner's Court.

Tan described the night as "particularly busy" and the hospital had admitted 20 patients between 10.30pm and 8am the next day.

Ian Powell, Executive Director of the Association of Salaried Medical Specialists, was not surprised to hear of a basic procedural error occurring during a period of high stress in a hospital.


"It is quite understandable to see quite a basic procedure missed, or a check not done, when you are under constant pressure all the time," he said.

New Zealand's public hospitals have "entrenched shortages" of staff that lead to doctors being overworked and result in mistakes, he said. "When you start getting chinks in the system, then you create that risk to patients."

Last week a leaked email from Auckland District Health Board about tackling a $12m budget deficit lifted the lid on the financial constraints faced by all DHBs, with Auckland chief executive Ailsa Claire saying financial concerns were "a constant for all DHBs".

Powell fears this will continue to create dangers for patients.

"[Staff] shortages are being compounded by underfunding. It is a devastating combination. The risk to patient safety will logically increase as a consequence of that environment."

The doctor who first saw Bourke when he was admitted to the emergency department was concerned the pain he was experiencing suggested a heart infection, and requested a chest X-ray as she transferred him to the Assessment and Diagnostic Unit (ADU).

However, Tan, the registrar in ADU, assessed Bourke as suffering from respiratory infection at 1.50am. He failed to return to Bourke to review the X-ray results that were available at 2.36am.

Dr Tan acknowledged he would have been aware of the X-ray request when the patient was handed over, and that the patient volume meant he forgot to return to Bourke. The next day the consultant physician seeing Bourke assessed the X-ray, observed a widening of the mediastinum (the central part of the chest), and ordered a CT scan to rule out dissection of the aorta.

At 10.45am Bourke had sudden severe chest pain, became short of breath and collapsed as he was being positioned in the CT scanner. A lengthy resuscitation attempt failed, and he was pronounced dead at 11.30am. Had he been quickly and correctly diagnosed, he had an estimated 60 per cent chance of survival.

"Those are pretty good odds. We would have liked the chance for him to be one of those three [in five]," his wife, Paddy Martin, told the court.

The family was angry that the crucial X-ray had gone unseen until the morning.

"If only I had asked what was on his X-ray, maybe someone would have looked at it. What is the point of doing an X-ray if you are not going to look at it? He wasn't given a chance," she said.

The head of department at North Shore hospital stressed that the symptoms Bourke presented were not typical of aortic dissection, and that it was a very rare condition, but he recognised the failure to pick up the early-warning sign.

"The lack of overnight review of the X-ray was a missed opportunity, and I sincerely apologise."

Bourke's care "did not meet the standards we expect at Waitemata," said Dr Jonathan Christiansen, clinical director medicine and health of older people, Waitemata DHB.

As a result of Bourke's death, the hospital reviewed its overnight staffing and is trialling phone and web-based systems to improve after-hours communication between doctors and nurses.

Sunday Star Times