Relatives of a young mother who died after a stem cell transplant at Wellington Hospital say medical staff did not do enough after she contracted a superbug.
Andrea Tabernacle, 30, died of multiple organ failure, toxic shock and leukaemia on December 2, 2009.
Her mother, Rozalia Biczo, wrote to the coroner in late 2010 and a coronial investigation was launched. The coroner investigated her death at an inquest in Wellington this week.
The Napier trainee nurse was infected with the antibiotic-resistant bacteria MRSA, and her finger had to be amputated.
"We've been to hell and back because of the events that unfolded," her mother, Rozalia Biczo, told The Dominion Post.
The hospital failed to screen Ms Tabernacle for MRSA - an oversight it admitted at the inquest. It also agreed that communication with the family could have been better.
But doctors said Ms Tabernacle had received the highest standard of care and that detecting MRSA earlier would not have changed the outcome.
While it is not clear how Ms Tabernacle contracted MRSA, doctors agreed it could have been during one of the many finger-prick tests done by nurses in the weeks before she died.
"When my daughter died they came into ICU and said to us, while she was lying there: 'Mistakes have been made'," Ms Biczo said. "While they admitted to those mistakes, they never said sorry. She suffered a treatment injury and they failed to have systems in place to protect her."
Ms Tabernacle, who had two young sons, was diagnosed with T-cell leukaemia-lymphoma and acute lymphoblastic leukaemia in June 2009.
After four months of intensive chemotherapy at Palmerston North Hospital, she was transferred to Wellington Hospital for the transplant on November 5.
Her health began to deteriorate on November 10 while she was recovering in the transplant unit.
The pain in her finger was increasing, but no specific tests were ordered.
Ms Biczo arrived in Wellington on November 14 to find her daughter gravely ill.
Her finger had begun to go black, she was retaining fluid around her neck, and she was struggling to breathe. "When I saw her, I panicked. I couldn't believe she was still in the ward."
At the inquest, Ms Biczo criticised the hospital for failing to screen her daughter for MRSA, for not taking her to ICU earlier and for not amputating her finger sooner.
She was also concerned about protocol around finger-pricking, which she claimed was how Ms Tabernacle contracted MRSA.
"If she hadn't suffered the finger-prick, I'm absolutely certain Andrea would have survived the transplant. I was able to prove that her body was accepting the stem cell transplant," she told The Dominion Post.
Ms Biczo, who is a nurse in Hawke's Bay, told the coroner that she had witnessed ward nurses doing finger-pricks without cleaning the skin.
Clinical leader of haematology Dr John Carter told the coroner there was no way of knowing whether this was how Ms Tabernacle got MRSA, but she was not screened for it when she should have been.
Had it been detected earlier, however, it would not have changed her treatment or outcome.
Dr Carter said an earlier transfer to ICU was not needed as staff in the unit had the skills to deal with her situation.
At the inquest, Ms Biczo criticised how doctors explained the 10-20 per cent risk of dying after the transplant.
Ms Tabernacle perceived this risk was low, when it was high.
She was also of the belief that her case would be used for research, when it was not.
Coroner Ian Smith said communication between medical staff and the family was an issue, but was not uncommon in cases like this.
ICU clinical leader Shawn Sturland told the coroner it was hospital policy to ask family to leave a patient's bedside during ward rounds and he had kept Ms Biczo informed during the ordeal.
Ms Biczo said doctors had ignored her pleas to amputate the finger earlier, but Dr Sturland said there were concerns about Ms Tabernacle surviving surgery.
By the time they operated on November 18, the chance of her surviving was slim.
Dr Sturland confirmed he had told Ms Biczo her daughter had been "harmed under care".
ACC took 12 months to approve a treatment injury claim.
Mr Smith reserved his findings.
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