Health and Disability Commissioner orders Health NZ to apologise to family of woman who died of sepsis after procedure
- Hge News
- Feb 3
- 3 min read
When a woman underwent an outpatient procedure to remove cancer from her small intestine, a suspected perforation occurred and she was admitted to hospital as a precautionary measure.
But during her admission, the woman’s condition deteriorated and she was diagnosed with pancreatitis.
Three weeks after the initial procedure, the woman, in her 70s, had emergency surgery to treat the perforation but died days later of sepsis.
Now, Deputy Health and Disability Commissioner Carolyn Cooper has released a report into the woman’s post-operative care which found several deficiencies.
Cooper said the inadequate care provided was not the result of isolated incidents involving one or two staff.
“They were widespread, involving many staff members, which is a reflection of Health NZ’s poor systems at the time, which I consider constitutes a departure from the expected standard of care for [the woman].”
According to the report released today, the woman’s case was brought to the attention of the Health and Disability Commissioner (HDC) in a complaint by her grandson about her care.
The report, which does not name the woman or the health board involved, said the procedure used to remove the woman’s cancer was technically complex and risked perforation, bleeding, and pancreatitis.
While the cancer was successfully removed, it was recorded there was a possible micro-perforation at the opening of the woman’s pancreatic duct caused by a thin wire used to control the movement of equipment during surgery.
The gastroenterologist who performed the surgery inserted a metal stent, a tube to open the passageway, as a standard treatment for possible perforations.
The patient was admitted to hospital and given antibiotics.
But during her stay she developed pancreatitis and her condition fluctuated between periods of improvement and deterioration.
She was managed non-surgically under the care of four specialists.
The report stated she was cared for in the gastroenterology ward where she suffered vomiting, nausea, bloating and abdominal pain.
She was given intravenous fluids, anti-nausea medication and pain relief, and had
X-rays that were considered normal and did not show evidence of perforation.
However, blood tests later showed the woman’s inflammatory markers were elevated, and she had a fever.
After further investigation, a CT scan reported a swollen pancreas with mild to moderate amounts of free fluid.
The scan was consistent with moderately severe pancreatitis but also did not show a perforation.
The woman’s care was transferred to general surgery, where her symptoms continued to fluctuate and her temperature spiked at least once a day.
She was reviewed four times and it was noted that despite her pancreatitis, she was eating and drinking and that she was “bloated but a lot better”.
A secondary diagnosis of constipation and dehydration was made, and a dietary plan was made that included laxatives.
The woman’s temperatures continued to spike but a registrar explained that post-procedure bloating was expected, and she could be discharged if her fevers settled and she was eating and drinking normally.
Her care was eventually transferred to an upper GI specialist who went on to suspect the woman likely had a contained “retroperitoneal type two perforation” and that this was complicated by pancreatitis.
The specialist ordered a further CT scan, dietitian input and antibiotics to continue.
The scan showed no abscess but indicated a progressive inflammatory change of the duodenum, the first part of the small intestine, and pancreas, with a moderate fluid collection.
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